Provider Demographics
NPI:1700054236
Name:JOHANSEN, RANDI MARIE (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:MARIE
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 RTE 23N
Mailing Address - Street 2:SUITE E
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457
Mailing Address - Country:US
Mailing Address - Phone:973-248-1188
Mailing Address - Fax:973-248-1125
Practice Address - Street 1:92 RTE 23N
Practice Address - Street 2:SUITE E
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457
Practice Address - Country:US
Practice Address - Phone:973-248-1188
Practice Address - Fax:973-248-1125
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00352000156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician