Provider Demographics
NPI:1194945717
Name:HANSON, RANDAL LINN (OD)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:LINN
Last Name:HANSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 SW 3RD CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2586
Mailing Address - Country:US
Mailing Address - Phone:239-823-2576
Mailing Address - Fax:
Practice Address - Street 1:4600 SUMMERLIN ROAD
Practice Address - Street 2:SUITE C4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3003
Practice Address - Country:US
Practice Address - Phone:239-936-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU69491Medicare UPIN
FL20792CMedicare ID - Type Unspecified