Provider Demographics
NPI:1326253998
Name:KIMPLE, RANDALL J (MD PHD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:KIMPLE
Suffix:
Gender:M
Credentials:MD PHD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3148 WIMR
Mailing Address - Street 2:1111 HIGHLAND AVE
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:608-265-3716
Mailing Address - Fax:
Practice Address - Street 1:1111 HIGHLAND AVE
Practice Address - Street 2:WIMR 3148
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2275
Practice Address - Country:US
Practice Address - Phone:608-655-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI550032085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC55774UMedicare UPIN