Provider Demographics
NPI:1265423248
Name:MYERS, RANDALL EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:EDWARD
Last Name:MYERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PALUSTER ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2532
Mailing Address - Country:US
Mailing Address - Phone:231-775-7341
Mailing Address - Fax:231-775-3925
Practice Address - Street 1:120 PALUSTER ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2532
Practice Address - Country:US
Practice Address - Phone:231-775-7341
Practice Address - Fax:231-775-3925
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5098279Medicaid
MI0H37621Medicare PIN
MI5098279Medicaid