Provider Demographics
NPI:1265496947
Name:ZUCKERMAN, RANDALL S (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
Last Name:ZUCKERMAN
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 1:1333 SURGICAL SERVICES WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4844
Mailing Address - Country:US
Mailing Address - Phone:406-751-5392
Mailing Address - Fax:
Practice Address - Street 1:1333 SURGICAL SERVICES WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4844
Practice Address - Country:US
Practice Address - Phone:406-751-5392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT42017208600000X
VT042-0012024208600000X
CT046606208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD3929Medicare ID - Type UnspecifiedUPSTATE
NYH76651Medicare UPIN
CTD400000410Medicare PIN
NY02359979Medicaid