Provider Demographics
NPI:1093828782
Name:NACKE, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:NACKE
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 13
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019
Mailing Address - Country:US
Mailing Address - Phone:636-937-8855
Mailing Address - Fax:636-931-6561
Practice Address - Street 1:1400 HWY 61 SOUTH
Practice Address - Street 2:SUITE 130
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019
Practice Address - Country:US
Practice Address - Phone:636-937-8855
Practice Address - Fax:636-931-6561
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTP10024907207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI74053Medicare UPIN