Provider Demographics
NPI:1336142009
Name:OW, RANDALL A
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:A
Last Name:OW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EXPOSITION BLVD
Mailing Address - Street 2:BLDG 700
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-736-3408
Mailing Address - Fax:916-233-4171
Practice Address - Street 1:2 MEDICAL PLAZA DR
Practice Address - Street 2:STE 225 & 235
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3043
Practice Address - Country:US
Practice Address - Phone:916-782-1391
Practice Address - Fax:916-782-5992
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86601207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA040017418OtherRR MEDICARE PIN
CAH68394Medicare UPIN
CAAW831ZMedicare PIN