Provider Demographics
NPI:1538135504
Name:WARREN, RANDALL C (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:C
Last Name:WARREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RANDALL
Other - Middle Name:C
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11475 ROBINSON DR NW
Mailing Address - Street 2:21110Q
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3746
Mailing Address - Country:US
Mailing Address - Phone:763-587-9000
Mailing Address - Fax:763-587-9130
Practice Address - Street 1:11475 ROBINSON DR NW
Practice Address - Street 2:21110Q
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3746
Practice Address - Country:US
Practice Address - Phone:763-587-9000
Practice Address - Fax:763-587-9130
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25916208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN958502800Medicaid
MN958502800Medicaid
370002046Medicare ID - Type Unspecified