Provider Demographics
NPI:1083612006
Name:KRYSTOSEK, RANDALL JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAMES
Last Name:KRYSTOSEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 SAINT MARYS DR W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0512
Mailing Address - Country:US
Mailing Address - Phone:812-477-9241
Mailing Address - Fax:812-474-6708
Practice Address - Street 1:801 SAINT MARYS DR W
Practice Address - Street 2:SUITE 300
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0512
Practice Address - Country:US
Practice Address - Phone:812-477-9241
Practice Address - Fax:812-474-6708
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1028039A208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64755499Medicaid
KY64755499Medicaid
IND95058Medicare UPIN