Provider Demographics
NPI:1871767814
Name:JOHN G RANDALL
Entity type:Organization
Organization Name:JOHN G RANDALL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-892-4292
Mailing Address - Street 1:2306 N TRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-2517
Mailing Address - Country:US
Mailing Address - Phone:903-892-4292
Mailing Address - Fax:903-893-8734
Practice Address - Street 1:2306 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-2517
Practice Address - Country:US
Practice Address - Phone:903-892-4292
Practice Address - Fax:903-893-8734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5449TG332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019078701Medicaid
SC1871767814Medicare NSC
SC4269780001Medicare NSC
TX019078701Medicaid