Provider Demographics
NPI:1881745032
Name:KINKADE, RANDOLPH CLAY (OD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:CLAY
Last Name:KINKADE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 WEST ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3502
Mailing Address - Country:US
Mailing Address - Phone:860-567-3133
Mailing Address - Fax:
Practice Address - Street 1:63 WEST ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3502
Practice Address - Country:US
Practice Address - Phone:860-567-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT935152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410000326Medicare PIN
T22373Medicare UPIN