Healthcare Provider Details

I. General information

NPI: 1194945717
Provider Name (Legal Business Name): RANDAL LINN HANSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 SUMMERLIN ROAD SUITE C4
FORT MYERS FL
33919-3003
US

IV. Provider business mailing address

711 SW 3RD CT
CAPE CORAL FL
33991-2586
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-2121
  • Fax:
Mailing address:
  • Phone: 239-823-2576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3118
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: