Provider Demographics
NPI:1326012832
Name:RANDALL, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
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 1:968 WAYNOKA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WAYNOKA
Mailing Address - State:OH
Mailing Address - Zip Code:45171-9762
Mailing Address - Country:US
Mailing Address - Phone:937-446-1639
Mailing Address - Fax:
Practice Address - Street 1:1275 N HIGH ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-8273
Practice Address - Country:US
Practice Address - Phone:937-393-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-073247207Q00000X
OH35.073247207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000344443OtherANTHEM BCBS
P00190832OtherRAILROAD MEDICARE
OH2418155Medicaid
P00190832OtherRAILROAD MEDICARE
OH000000344443OtherANTHEM BCBS