Provider Demographics
NPI:1124775168
Name:MCMILLAN, RANDYN SHAMAR (CO, LDO)
Entity type:Individual
Prefix:MR
First Name:RANDYN
Middle Name:SHAMAR
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:CO, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 MADISON AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-7400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE STE 400
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-7400
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO3507156FX1800X
FLLDO7360156FX1800X
156FX1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1900XEye and Vision Services ProvidersTechnician/TechnologistOrthoptist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician