Provider Demographics
NPI:1780640391
Name:JOHNSON, RANDALL RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:RICHARD
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 1:102 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-5922
Mailing Address - Country:US
Mailing Address - Phone:563-386-1950
Mailing Address - Fax:563-386-1021
Practice Address - Street 1:102 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5922
Practice Address - Country:US
Practice Address - Phone:563-386-1950
Practice Address - Fax:563-386-1021
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
37150OtherBCBS
J01642089OtherCLARITY VISION
U93866Medicare UPIN
P00275886Medicare ID - Type UnspecifiedRAILROAD
I16704Medicare ID - Type Unspecified