Provider Demographics
NPI:1841245057
Name:JOHNSON, RANDALL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2550 NORTH HOLLYWOOD WAY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-5019
Mailing Address - Country:US
Mailing Address - Phone:818-557-0135
Mailing Address - Fax:818-557-1394
Practice Address - Street 1:4081 EAST OLYMPIC BOULEVARD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3330
Practice Address - Country:US
Practice Address - Phone:323-881-2666
Practice Address - Fax:323-267-4530
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34657207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA930092507OtherLA COMMUNITY RAILROAD
CA00G346570OtherBLUE SHIELD
CA00G346570OtherCALOPTIMA
CA00G346570Medicaid
CA050663CA46019OtherLA COMMUNITY TRAILBLAZER
CAG34657OtherBLUE CROSS
CAWG34657DMedicare Oscar/Certification
CA00G346570OtherCALOPTIMA
CA930092507OtherLA COMMUNITY RAILROAD