Provider Demographics
NPI:1215979976
Name:FUJA, RANDY L (OD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:L
Last Name:FUJA
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 1:2631FOOTHILL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4591
Mailing Address - Country:US
Mailing Address - Phone:307-362-4202
Mailing Address - Fax:307-362-4332
Practice Address - Street 1:2631FOOTHILL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4770
Practice Address - Country:US
Practice Address - Phone:307-362-4202
Practice Address - Fax:307-362-4332
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY214T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY108096200Medicaid
WY410019956OtherRAILROAD MEDICARE
UT410026623OtherRAILROAD MEDICARE
WYW4510007Medicare ID - Type Unspecified
UT410026623OtherRAILROAD MEDICARE