Provider Demographics
NPI:1245480185
Name:JOHNSON, RANDALL VICTOR (IDC)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:VICTOR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 USS JAMES MADISON RD
Mailing Address - Street 2:
Mailing Address - City:KINGS BAY
Mailing Address - State:GA
Mailing Address - Zip Code:31547-2531
Mailing Address - Country:US
Mailing Address - Phone:912-592-0005
Mailing Address - Fax:912-573-4534
Practice Address - Street 1:USS WEST VIRGINIA (SSBN 736) (BLUE)
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34093-2123
Practice Address - Country:US
Practice Address - Phone:912-674-8685
Practice Address - Fax:912-573-4534
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman