Provider Demographics
NPI:1104829134
Name:FALCONER, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:FALCONER
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 1:1728 N EASTMAN RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2371
Mailing Address - Country:US
Mailing Address - Phone:423-230-6532
Mailing Address - Fax:423-230-4859
Practice Address - Street 1:1728 N EASTMAN RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2371
Practice Address - Country:US
Practice Address - Phone:423-230-6532
Practice Address - Fax:423-230-4859
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 18839207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6502512Medicaid
TN3036752Medicaid
TN3036753Medicare ID - Type Unspecified
TN6502512Medicare ID - Type Unspecified
TN3036752Medicaid