Provider Demographics
NPI:1083627236
Name:MILLER, RANDALL (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:MILLER
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-222-7000
Mailing Address - Fax:515-222-2737
Practice Address - Street 1:1601 NW 114TH ST
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7007
Practice Address - Country:US
Practice Address - Phone:515-222-7000
Practice Address - Fax:515-222-2737
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA068119OtherWELLMARK-MANAGED CARE
IA6271T2OtherJOHN DEERE
IA1181123Medicaid
IA51297OtherWELLMARK
IA51297OtherWELLMARK
IA1181123Medicaid