Provider Demographics
NPI:1982695524
Name:RANDALL, JOHN WILFRED (OD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILFRED
Last Name:RANDALL
Suffix:
Gender:M
Credentials:OD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 EILER LN
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9731
Mailing Address - Country:US
Mailing Address - Phone:509-865-1877
Mailing Address - Fax:
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:PACIFIC UNIVERSITY COLLEGE OF OPTOMETRY
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1756
Practice Address - Country:US
Practice Address - Phone:503-352-2020
Practice Address - Fax:503-352-2929
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1610AT152W00000X
OK1012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U99833Medicare UPIN