Basic Information
| Provider Information | |||||||||
| NPI: | 1902891468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUTTON | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | OPTOMETRIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 VILLAGE LN | ||||||||
| Address2: | |||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327808745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212693405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1381 S PATRICK DR | ||||||||
| Address2: | |||||||||
| City: | PATRICK AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329253606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214948164 | ||||||||
| FaxNumber: | 3214941378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1827 | MN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.