Provider Demographics
NPI:1568557940
Name:JOHNSON, RANDAL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:LEE
Last Name:JOHNSON
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 1:1450 E RAM CANYON DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-9294
Mailing Address - Country:US
Mailing Address - Phone:520-838-1990
Mailing Address - Fax:
Practice Address - Street 1:6987 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4224
Practice Address - Country:US
Practice Address - Phone:520-297-2501
Practice Address - Fax:520-297-9496
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001139152W00000X
UT6249139-9934152W00000X
FL0002237152W00000X
AZOPT-001878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty