Provider Demographics
NPI:1487681409
Name:SMART, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:SMART
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MURPHYS
Mailing Address - State:CA
Mailing Address - Zip Code:95247-0306
Mailing Address - Country:US
Mailing Address - Phone:209-890-7758
Mailing Address - Fax:209-890-7759
Practice Address - Street 1:300 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MURPHYS
Practice Address - State:CA
Practice Address - Zip Code:95247-0306
Practice Address - Country:US
Practice Address - Phone:209-890-7758
Practice Address - Fax:209-890-7759
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61777207R00000X
AK3984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G617770Medicaid
CA00G617770Medicare ID - Type Unspecified
H65228Medicare UPIN