Provider Demographics
NPI:1326029679
Name:RANDALL, RICHARD R (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:420 LOWELL DR SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3754
Mailing Address - Country:US
Mailing Address - Phone:256-535-5940
Mailing Address - Fax:256-535-5954
Practice Address - Street 1:401 LOWELL DR SE
Practice Address - Street 2:SUITE 10
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3748
Practice Address - Country:US
Practice Address - Phone:256-535-5948
Practice Address - Fax:256-535-5951
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20661208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000096070Medicaid
AL51096070OtherBLUE CROSS
0005671483OtherAETNA
020046829OtherRAILROAD MEDICARE
631247522OtherTAX ID
0005671483OtherAETNA
F92542Medicare UPIN