Provider Demographics
NPI:1194795435
Name:OFFUTT, RANDOLPH LYONS (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:LYONS
Last Name:OFFUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:101 MEDICAL HEIGHTS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-4137
Mailing Address - Country:US
Mailing Address - Phone:502-227-4828
Mailing Address - Fax:502-227-3073
Practice Address - Street 1:101 MEDICAL HEIGHTS DR
Practice Address - Street 2:SUITE B
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4137
Practice Address - Country:US
Practice Address - Phone:502-227-4828
Practice Address - Fax:502-227-3073
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2010-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY19201207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64192016Medicaid
KY64192016Medicaid
KY1153320001Medicare NSC