Provider Demographics
NPI:1366518011
Name:GOLDMAN, RANDY KENNETH (OD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:KENNETH
Last Name:GOLDMAN
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 1:39 PHILIP STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052
Mailing Address - Country:US
Mailing Address - Phone:508-359-6401
Mailing Address - Fax:781-449-0777
Practice Address - Street 1:1211 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:781-449-4090
Practice Address - Fax:781-449-0777
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2742152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
762250OtherTUFTS
T59299OtherEAST SENORITY
W15573OtherBCBS
42930OtherDAVIS VISION
MA0343471Medicaid
MA2742OtherEYE MED
W15573OtherBCBS
T59299OtherEAST SENORITY