Provider Demographics
NPI:1043283336
Name:KJORSTAD, RANDY J (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:J
Last Name:KJORSTAD
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:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7690
Mailing Address - Fax:307-739-7644
Practice Address - Street 1:1245 NW 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-548-7761
Practice Address - Fax:541-598-3485
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9325208600000X
MT12855208600000X
WY9756A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW26189OtherSJMC PTAN