Provider Demographics
NPI:1528061835
Name:RANDLE, CLIFTON J III (OD)
Entity type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:J
Last Name:RANDLE
Suffix:III
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 1:213 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-1505
Mailing Address - Country:US
Mailing Address - Phone:931-823-3380
Mailing Address - Fax:
Practice Address - Street 1:1205 OLD HWY 127S
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-3030
Practice Address - Country:US
Practice Address - Phone:931-879-5897
Practice Address - Fax:931-879-8166
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595164Medicaid
TN3595167Medicaid
TN3149057OtherBCBS
TN3595162Medicaid
TN3595167Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER
TN3595162Medicaid
TN3595167Medicaid
TN3595164Medicare PIN
TN3149057OtherBCBS
TNT61230Medicare UPIN