Provider Demographics
NPI:1386688422
Name:MOELLER, RANDALL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAMES
Last Name:MOELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9398 RIDGETOP BLVD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8505
Practice Address - Country:US
Practice Address - Phone:360-782-3200
Practice Address - Fax:360-782-3244
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044442208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3745243OtherAETNA
P00212141OtherRAILROAD MEDICARE
1153MOOtherREGENCE BLUE SHIELD
WA193291OtherLABOR & INDUSTRIES
WA8421752Medicaid
AM9584005OtherDEA
WA193291OtherLABOR & INDUSTRIES
WAG8852251Medicare PIN
WA8421752Medicaid
C51741Medicare UPIN
WAG8852254Medicare PIN
1153MOOtherREGENCE BLUE SHIELD
WAG8856172Medicare PIN
WAG8853499Medicare PIN