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NPI Code Detail

MEDICARE: DR. JOHN WILFRED RANDALL OD, MPH

MEDICARE: DR. JOHN WILFRED RANDALL OD, MPH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist1610ATOR
2152W00000XOptometrist1012OK

General Provider Information

NPI Number : 1982695524
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JOHN WILFRED RANDALL OD, MPH
Provider Business Mailing Address
First Line : 30 EILER LN
Second Line :
City : ZILLAH
State : WA
Zip : 98953-9731
Country : US
Telephone Number : 509-865-1877
Fax Number :
Provider Business Practice Location Address
First Line : 2043 COLLEGE WAY
Second Line : PACIFIC UNIVERSITY COLLEGE OF OPTOMETRY
City : FOREST GROVE
State : OR
Zip : 97116-1756
Country : US
Telephone Number : 503-352-2020
Fax Number : 503-352-2929
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/02/2005
Last Update Date : 07/08/2007

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