Provider Demographics
NPI:1629077359
Name:FENTON, RANDALL CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:CLARK
Last Name:FENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:29 STILES RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-5802
Mailing Address - Country:US
Mailing Address - Phone:603-870-5452
Mailing Address - Fax:603-870-5449
Practice Address - Street 1:29 STILES RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-5802
Practice Address - Country:US
Practice Address - Phone:603-870-5452
Practice Address - Fax:603-870-5449
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH9962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
753299OtherTUFTS HEALTHPLAN
407866OtherUNIFORMED SERVICES FAMILY
J17896OtherBCBS OF MASSACHUSETTS
66951OtherCIGNA
0100419YPNH01OtherANTHEM BCBS NEW HAMPSHIRE
71838OtherHARVARD PILGRIM HEALTHCAR
2637002OtherAETNA
71838OtherHARVARD PILGRIM HEALTHCAR
753299OtherTUFTS HEALTHPLAN