Provider Demographics
NPI:1588687602
Name:TEAGUE, RANDALL L (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:TEAGUE
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 1:11115 HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3807
Mailing Address - Country:US
Mailing Address - Phone:501-224-7056
Mailing Address - Fax:501-224-4327
Practice Address - Street 1:11115 HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3807
Practice Address - Country:US
Practice Address - Phone:501-224-7056
Practice Address - Fax:501-224-4327
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105488722Medicaid
AR105488722Medicaid
AR0341010001Medicare NSC
AR49077Medicare ID - Type Unspecified