Provider Demographics
NPI:1487639621
Name:MCKISSACK, RANDALL LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LOUIS
Last Name:MCKISSACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8269
Mailing Address - Fax:850-862-7965
Practice Address - Street 1:999 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6758
Practice Address - Country:US
Practice Address - Phone:850-863-8269
Practice Address - Fax:850-862-7965
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96715208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277632400Medicaid
AL32682OtherBCBS OF ALABAMA PROVIDER
AL000032682Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
AL32682OtherBCBS OF ALABAMA PROVIDER