Provider Demographics
NPI:1326076530
Name:RANDALL, JOHN K (RPH, MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:RANDALL
Suffix:
Gender:M
Credentials:RPH, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAGAMORE PKWY W
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1569
Mailing Address - Country:US
Mailing Address - Phone:765-463-6722
Mailing Address - Fax:765-463-0905
Practice Address - Street 1:124 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1569
Practice Address - Country:US
Practice Address - Phone:765-463-6722
Practice Address - Fax:765-463-0905
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042716207N00000X, 207ND0900X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092649OtherBCBS
IN01042716OtherLICENSE
IN200207110AMedicaid
IN100415730AMedicaid
IN01042716BOtherCSR
BR1531385OtherDEA
IN000000092649OtherBCBS