Provider Demographics
NPI:1699746644
Name:LIEBE, RANDALL ARDELL (OD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:ARDELL
Last Name:LIEBE
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 1:122 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-2815
Mailing Address - Country:US
Mailing Address - Phone:641-472-6694
Mailing Address - Fax:641-472-5979
Practice Address - Street 1:122 N COURT ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-2815
Practice Address - Country:US
Practice Address - Phone:641-472-6694
Practice Address - Fax:641-472-5979
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA410020712OtherRAILROAD MEDICARE
IA26496OtherBLUE CROSS BLUE SHIELD
IA0264960Medicaid
IA26496Medicare PIN
IA0264960Medicaid
IA3205190001Medicare NSC