Provider Demographics
NPI:1184636672
Name:RANDALL, KATHRYN KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:KIMBERLY
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 S. 8TH ST.
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030
Mailing Address - Country:US
Mailing Address - Phone:575-543-7200
Mailing Address - Fax:575-543-7253
Practice Address - Street 1:905 S. 8TH ST.
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030
Practice Address - Country:US
Practice Address - Phone:575-543-7200
Practice Address - Fax:575-543-7253
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7343A207V00000X
NMMD2013-0007207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology