Provider Demographics
NPI:1457491904
Name:DAVAULT, RANDALL JASON (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JASON
Last Name:DAVAULT
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 1:1706 DELIVERY LN
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2292
Mailing Address - Country:US
Mailing Address - Phone:580-924-0110
Mailing Address - Fax:580-920-9976
Practice Address - Street 1:1706 DELIVERY LN
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2292
Practice Address - Country:US
Practice Address - Phone:580-924-0110
Practice Address - Fax:580-920-9976
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23575208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5204Medicare PIN