Provider Demographics
NPI:1447213673
Name:KING, RANDALL W (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:W
Last Name:KING
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047670207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000371637OtherBC/BS # ST VOBS
OH727073OtherBUCKEYE COMMUNITY NUMBER
OH0540847Medicaid
OHP00209987OtherRAILROAD MEDICARE NUMBER
OH000000360656OtherBC/BS INDIVIDUAL NUMBER
OH104734103Medicaid
OH104758929Medicaid
OH000000360656OtherBC/BS INDIVIDUAL NUMBER
OHKI0522876Medicare ID - Type UnspecifiedIND MEDICARE PROVIDER #
OH104734103Medicaid