Provider Demographics
NPI:1588728711
Name:ROELFS, RANDALL G (O D)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:G
Last Name:ROELFS
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:STAUNTON PLAZA SHOPPING CENTER
Mailing Address - City:HURT
Mailing Address - State:VA
Mailing Address - Zip Code:24563-0610
Mailing Address - Country:US
Mailing Address - Phone:434-324-8855
Mailing Address - Fax:434-324-8852
Practice Address - Street 1:STAUNTON PLAZA SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:HURT
Practice Address - State:VA
Practice Address - Zip Code:24563-0610
Practice Address - Country:US
Practice Address - Phone:434-324-8855
Practice Address - Fax:434-324-8852
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01362Medicare PIN
VAC01361Medicare PIN