Provider Demographics
NPI:1134221864
Name:HOLLOWAY, RANDALL (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:HOLLOWAY
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 1:4 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-1309
Mailing Address - Country:US
Mailing Address - Phone:620-223-0850
Mailing Address - Fax:
Practice Address - Street 1:4 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-1309
Practice Address - Country:US
Practice Address - Phone:620-223-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1184-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100217910AMedicaid
KS410008912OtherRAILROAD MEDICARE
KST43665Medicare UPIN
KS100217910AMedicaid
KS05131Medicare ID - Type Unspecified