Provider Demographics
NPI:1083610414
Name:CULBERTSON, RANDALL LEE (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:CULBERTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29508 E PINK HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-9258
Mailing Address - Country:US
Mailing Address - Phone:816-228-9448
Mailing Address - Fax:816-246-4850
Practice Address - Street 1:29508 E PINK HILL RD
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-9258
Practice Address - Country:US
Practice Address - Phone:816-251-4724
Practice Address - Fax:816-246-4850
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2D26207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOD16867Medicare UPIN