Provider Demographics
NPI:1639130826
Name:WOODWORTH, RANDON BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:RANDON
Middle Name:BLAKE
Last Name:WOODWORTH
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 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:407 W 66TH ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2374
Practice Address - Country:US
Practice Address - Phone:612-798-8800
Practice Address - Fax:612-798-8816
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN510877200Medicaid
MN510877200Medicaid
MN080020968Medicare PIN