Provider Demographics
NPI:1508906868
Name:RANDAZZO, LEONARD M (OD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:M
Last Name:RANDAZZO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4135 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-1211
Mailing Address - Country:US
Mailing Address - Phone:708-457-1113
Mailing Address - Fax:708-457-8528
Practice Address - Street 1:4135 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-1211
Practice Address - Country:US
Practice Address - Phone:708-457-1113
Practice Address - Fax:708-457-8528
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46008337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU39212Medicare UPIN