Provider Demographics
NPI:1215912472
Name:CUMMINGS, RANDALL PERRY (OD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:PERRY
Last Name:CUMMINGS
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 1:1420 S BLAINE ST STE 6
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3973
Mailing Address - Country:US
Mailing Address - Phone:208-882-2020
Mailing Address - Fax:208-882-2020
Practice Address - Street 1:1420 S BLAINE ST STE 6
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3973
Practice Address - Country:US
Practice Address - Phone:208-882-2020
Practice Address - Fax:208-882-2020
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP - 100097152WV0400X
IDODP-100097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807626700Medicaid
CAT10485Medicare UPIN