Provider Demographics
NPI:1386675627
Name:FILLMORE, RANDALL R (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3725 W 4100 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:801-965-3526
Practice Address - Street 1:2751 W 9000 SOUTH
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-352-5900
Practice Address - Fax:801-352-5914
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT1773791205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F20829Medicare UPIN