Provider Demographics
NPI:1326508854
Name:TINGLE, RANDOLPH KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:KENNETH
Last Name:TINGLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:TINGLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1100 N PALM CANYON DR STE 109
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4418
Mailing Address - Country:US
Mailing Address - Phone:760-992-7152
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3298
Practice Address - Country:US
Practice Address - Phone:714-456-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A19676207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program