Provider Demographics
NPI:1417024936
Name:ANSELMO, RANDALL SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:SCOTT
Last Name:ANSELMO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:417 MARSH POINT CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5865
Mailing Address - Country:US
Mailing Address - Phone:802-375-4005
Mailing Address - Fax:802-491-8231
Practice Address - Street 1:130 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5776
Practice Address - Country:US
Practice Address - Phone:904-826-3469
Practice Address - Fax:904-808-4608
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2024-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VT042-0010651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG-65837Medicare UPIN