Provider Demographics
NPI:1467410811
Name:RANDALL, JEFFREY C (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:RANDALL
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 1:325 MAINE STREET
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-505-2988
Mailing Address - Fax:
Practice Address - Street 1:6265 ROCK CHALK DR STE 1500
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-5232
Practice Address - Country:US
Practice Address - Phone:785-843-9125
Practice Address - Fax:785-505-5312
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0425975207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004240780001Medicaid
KS100279030AMedicaid