Provider Demographics
NPI:1194714071
Name:RIEMER, RANDALL JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JOHN
Last Name:RIEMER
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 1:207 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1436
Mailing Address - Country:US
Mailing Address - Phone:517-647-2020
Mailing Address - Fax:517-647-7677
Practice Address - Street 1:207 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1436
Practice Address - Country:US
Practice Address - Phone:517-647-2020
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI94-2913642Medicaid
MIOC46504Medicare ID - Type Unspecified
MI94-2913642Medicaid