Healthcare Provider Details

I. General information

NPI: 1194786053
Provider Name (Legal Business Name): RANDY BROWN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11226 GOLD EXPRESS DR STE 202
GOLD RIVER CA
95670
US

IV. Provider business mailing address

11226 GOLD EXPRESS DR STE 202
GOLD RIVER CA
95670
US

V. Phone/Fax

Practice location:
  • Phone: 916-635-1037
  • Fax: 916-635-7370
Mailing address:
  • Phone: 916-635-1037
  • Fax: 916-635-7370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberCA6850T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberCA6850T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: