Provider Demographics
NPI:1407951080
Name:RANDONO, JOHN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:RANDONO
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 1:1633 MEDCIAL CENTER POINT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-1906
Mailing Address - Country:US
Mailing Address - Phone:719-632-5109
Mailing Address - Fax:719-475-8963
Practice Address - Street 1:1633 MEDCIAL CENTER POINT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-1906
Practice Address - Country:US
Practice Address - Phone:719-632-5109
Practice Address - Fax:719-475-8963
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25269207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01252691Medicaid
CO01252691Medicaid
804833Medicare ID - Type Unspecified