MEDICARE: DR. CLIFTON J. RANDLE III 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	OD729	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3149057	OTHER	TN	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528061835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLIFTON J. RANDLE III O.D.

Provider Business Mailing Address
First Line	:	213 ROBERTS ST
Second Line	:
City	:	LIVINGSTON
State	:	TN
Zip	:	38570-1505
Country	:	US
Telephone Number	:	931-823-3380
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 OLD HWY 127S
Second Line	:
City	:	JAMESTOWN
State	:	TN
Zip	:	38556-3030
Country	:	US
Telephone Number	:	931-879-5897
Fax Number	:	931-879-8166

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	01/23/2009

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