Provider Demographics
NPI:1578669883
Name:DRAGT, RANDALL L (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:DRAGT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-2526
Mailing Address - Fax:
Practice Address - Street 1:202 E UPHAM ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1543
Practice Address - Country:US
Practice Address - Phone:715-384-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2914-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38995900OtherMEDICAID GROUP
CH1675OtherRAILROAD MEDICARE GROUP
WI38870300Medicaid
31834OtherSECURITY HEALTH PLAN
U38812Medicare UPIN