Provider Demographics
NPI:1588744296
Name:NELSON, RANDALL K (OD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:K
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:13955 E MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3692
Practice Address - Country:US
Practice Address - Phone:303-695-4999
Practice Address - Fax:303-695-0896
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC43203Medicare UPIN