Provider Demographics
NPI:1851512305
Name:RANDOLPH, JAMES PAUL (OD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:PAUL
Last Name:RANDOLPH
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 1:1960 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5206
Mailing Address - Country:US
Mailing Address - Phone:503-363-9011
Mailing Address - Fax:503-362-6376
Practice Address - Street 1:1960 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5206
Practice Address - Country:US
Practice Address - Phone:503-363-9011
Practice Address - Fax:503-362-6376
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1453 ATI ACTIVE152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR163352Medicaid
OR163352Medicaid
ORT68031Medicare UPIN