Provider Demographics
NPI:1336121441
Name:WILSON, RANDALL ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ALLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-1084
Mailing Address - Country:US
Mailing Address - Phone:859-734-3482
Mailing Address - Fax:859-734-3432
Practice Address - Street 1:106 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-1084
Practice Address - Country:US
Practice Address - Phone:859-734-3482
Practice Address - Fax:859-734-3432
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64332174Medicaid
KY1880201Medicare ID - Type Unspecified
KY64332174Medicaid