Provider Demographics
NPI:1962508762
Name:FORTNER, RANDAL JAMES JR (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:JAMES
Last Name:FORTNER
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4580 COUNTY ROAD FF
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-9306
Mailing Address - Country:US
Mailing Address - Phone:530-520-7793
Mailing Address - Fax:
Practice Address - Street 1:1158 PARK CITY CTR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2726
Practice Address - Country:US
Practice Address - Phone:717-393-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001844152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist