Healthcare Provider Details

I. General information

NPI: 1962617464
Provider Name (Legal Business Name): RANDALL EARL CONRAD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12845 POWAY RD STE. 209
POWAY CA
92064-4529
US

IV. Provider business mailing address

472 NILA
POWAY CA
92020
US

V. Phone/Fax

Practice location:
  • Phone: 858-748-6210
  • Fax: 858-748-6224
Mailing address:
  • Phone: 619-444-7269
  • Fax: 858-748-6224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number6423T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: