Provider Demographics
NPI:1558352138
Name:SELLERS, RANDALL E (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:E
Last Name:SELLERS
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 1:4411 THE 25 WAY NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5857
Mailing Address - Country:US
Mailing Address - Phone:505-332-6900
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-332-6900
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 0192402085R0202X
NMMD2013-06722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113321Medicaid
300054356OtherRR MEDICARE
LA1962945Medicaid
NM46678735Medicaid
300054356OtherRR MEDICARE
F36824Medicare UPIN