Provider Demographics
NPI:1003855206
Name:HEIDEL, RANDY S (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:HEIDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1348
Practice Address - Country:US
Practice Address - Phone:608-287-2250
Practice Address - Fax:608-287-2438
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36553-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003855206Medicaid
G04944Medicare UPIN
WI32131900Medicaid
WI4677OtherDEAN HEALTH INSURANCE
WI110116039Medicare PIN