Healthcare Provider Details

I. General information

NPI: 1114922218
Provider Name (Legal Business Name): RANDALL R HIEBER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date: 03/18/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

337 HARDING WAY W
GALION OH
44833-1725
US

IV. Provider business mailing address

337 HARDING WAY W
GALION OH
44833-1725
US

V. Phone/Fax

Practice location:
  • Phone: 419-468-3355
  • Fax: 419-468-7475
Mailing address:
  • Phone: 419-468-3355
  • Fax: 419-468-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3414/T925
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: