Provider Demographics
NPI:1376689257
Name:RANDALL, JEROME R JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:R
Last Name:RANDALL
Suffix:JR
Gender:M
Credentials:DPM
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Mailing Address - Street 1:19900 GOVERNORS DR
Mailing Address - Street 2:#12
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1057
Mailing Address - Country:US
Mailing Address - Phone:708-898-2380
Mailing Address - Fax:708-898-2326
Practice Address - Street 1:19900 GOVERNORS DR
Practice Address - Street 2:#12
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1057
Practice Address - Country:US
Practice Address - Phone:708-898-2380
Practice Address - Fax:708-898-2326
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-08-17
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Provider Licenses
StateLicense IDTaxonomies
IL016-005113213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005113Medicaid
ILK22685Medicare PIN
ILIL1517001Medicare PIN
ILIL2599001Medicare PIN