Provider Demographics
NPI:1033199914
Name:RANDALL, JOHN D (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:RANDALL
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 1:121 HEARTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7420
Mailing Address - Country:US
Mailing Address - Phone:803-359-2294
Mailing Address - Fax:803-359-1440
Practice Address - Street 1:314 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2657
Practice Address - Country:US
Practice Address - Phone:803-359-2294
Practice Address - Fax:803-359-1440
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13108Medicaid
SCD13108Medicaid