Provider Demographics
NPI:1124088422
Name:PICKENS, TODD RANDALL (OD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:RANDALL
Last Name:PICKENS
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 1:10 BRYSON DR
Mailing Address - Street 2:
Mailing Address - City:SUTTER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95685-4118
Mailing Address - Country:US
Mailing Address - Phone:209-223-1402
Mailing Address - Fax:
Practice Address - Street 1:10 BRYSON DR
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-4118
Practice Address - Country:US
Practice Address - Phone:209-223-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6317-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0063170Medicaid
CASD0063170Medicare PIN
CA0216300001Medicare NSC
CAT10289Medicare UPIN