Provider Demographics
NPI:1366447864
Name:PATKIN, RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:PATKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 HIGHLAND AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-7003
Mailing Address - Country:US
Mailing Address - Phone:978-744-1177
Mailing Address - Fax:978-910-0125
Practice Address - Street 1:400 HIGHLAND AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-7003
Practice Address - Country:US
Practice Address - Phone:978-744-1177
Practice Address - Fax:978-910-0125
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA70754207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3047288Medicaid
MA3047288Medicaid