Provider Demographics
NPI:1326368770
Name:RANDALL, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 NAAB RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1920
Mailing Address - Country:US
Mailing Address - Phone:317-871-0000
Mailing Address - Fax:317-871-0010
Practice Address - Street 1:8326 NAAB RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1920
Practice Address - Country:US
Practice Address - Phone:317-871-0000
Practice Address - Fax:317-871-0010
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076108A207R00000X, 207RH0003X
IN11015580A390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201102210Medicaid
IN201102210Medicaid