Provider Demographics
NPI:1497741870
Name:HART, RANDI WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDI
Middle Name:WAYNE
Last Name:HART
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-122022085R0202X
WAMD600975392085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0377781OtherL&I-RADIA KING COUNTY
WA0377786OtherL&I-SWEDISH RADIA EDMONDS
WA0377789OtherL&I-EVERGREEN RADIA
ID1497741870Medicaid
WA8552739Medicaid
WA0252750OtherL&I-RADIA REST OF WA
SD7207960Medicaid
SD7207960Medicaid
WA8883794Medicare PIN
WA252750OtherL&I
B53422Medicare UPIN