Provider Demographics
NPI:1144324260
Name:ETHRIDGE, RANDAL J (OD)
Entity type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:J
Last Name:ETHRIDGE
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 1:1200 AUSTIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801
Mailing Address - Country:US
Mailing Address - Phone:325-643-5511
Mailing Address - Fax:325-646-1496
Practice Address - Street 1:1200 AUSTIN AVENUE
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801
Practice Address - Country:US
Practice Address - Phone:325-643-5511
Practice Address - Fax:325-646-1496
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4460T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E39PMedicare PIN
U24228Medicare UPIN
TX0661180001Medicare NSC