Provider Demographics
NPI:1245237262
Name:RANDALL, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:RANDALL
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 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-747-5800
Mailing Address - Fax:360-575-3846
Practice Address - Street 1:1718 E KESSLER BLVD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1842
Practice Address - Country:US
Practice Address - Phone:360-747-5800
Practice Address - Fax:360-575-3846
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA81334OtherLABOR & IND
080099846OtherRR MEDICARE
OR057278Medicaid
WA8148116Medicaid
WA8933772OtherCRIME VICTIMS
WA81334OtherLABOR & IND
115106003Medicare ID - Type Unspecified