Healthcare Provider Details

I. General information

NPI: 1215912472
Provider Name (Legal Business Name): RANDALL PERRY CUMMINGS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S BLAINE ST STE 6
MOSCOW ID
83843-3973
US

IV. Provider business mailing address

1420 S BLAINE ST STE 6
MOSCOW ID
83843-3973
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-2020
  • Fax: 208-882-2020
Mailing address:
  • Phone: 208-882-2020
  • Fax: 208-882-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100097
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberODP - 100097
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: