Provider Demographics
NPI:1376525196
Name:ROUGH, RANDOLPH R (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:R
Last Name:ROUGH
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:PO BOX 9170
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-9170
Mailing Address - Country:US
Mailing Address - Phone:515-633-3600
Mailing Address - Fax:515-633-3838
Practice Address - Street 1:5880 UNIVERSITY AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8209
Practice Address - Country:US
Practice Address - Phone:515-633-3600
Practice Address - Fax:515-288-0840
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA23764207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0206607Medicaid
IA20660Medicare ID - Type Unspecified
IA0206607Medicaid