Healthcare Provider Details

I. General information

NPI: 1932103652
Provider Name (Legal Business Name): RANDY STEPHEN COSHATT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 5TH ST NE
ALICEVILLE AL
35442-2200
US

IV. Provider business mailing address

112 5TH ST NE
ALICEVILLE AL
35442-2200
US

V. Phone/Fax

Practice location:
  • Phone: 205-373-6374
  • Fax: 205-373-6163
Mailing address:
  • Phone: 205-373-6374
  • Fax: 205-373-6163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-375-TA-023
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: