Provider Demographics
NPI:1588612063
Name:LEA, RANDALL DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:DAVID
Last Name:LEA
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 1:10 ALICE PECK DAY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2900
Mailing Address - Country:US
Mailing Address - Phone:603-448-3121
Mailing Address - Fax:
Practice Address - Street 1:17 ALICE PECK DAY DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-2904
Practice Address - Country:US
Practice Address - Phone:603-442-5630
Practice Address - Fax:603-442-5631
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA015413207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3095403Medicaid
VT1021450Medicaid
LA1346420Medicaid
E06756Medicare UPIN
NH3095403Medicaid
VT1021450Medicaid