Provider Demographics
NPI:1598329575
Name:RANDALL, THOMAS SULLIVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:SULLIVAN
Last Name:RANDALL
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:PO BOX 15090
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92803-5090
Mailing Address - Country:US
Mailing Address - Phone:714-772-8282
Mailing Address - Fax:714-772-6493
Practice Address - Street 1:1211 W LA PALMA AVE STE 404
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2806
Practice Address - Country:US
Practice Address - Phone:714-772-8282
Practice Address - Fax:714-772-6493
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA180340208M00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program