MEDICARE: DR. RANDALL CARL PAUL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	AZ549	AZ

General Provider Information

NPI Number	:	1376672303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL CARL PAUL O.D.

Provider Business Mailing Address
First Line	:	15038 N 59TH PL
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85254-2476
Country	:	US
Telephone Number	:	602-992-6058
Fax Number	:

Provider Business Practice Location Address
First Line	:	21001 N TATUM BLVD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-4206
Country	:	US
Telephone Number	:	480-513-4184
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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