Provider Demographics
NPI:1659338093
Name:CORK, RANDY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:DEAN
Last Name:CORK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 MONTEREY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3102
Mailing Address - Country:US
Mailing Address - Phone:805-542-9700
Mailing Address - Fax:
Practice Address - Street 1:1100 MONTEREY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3102
Practice Address - Country:US
Practice Address - Phone:805-542-9700
Practice Address - Fax:805-542-0584
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG784782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF46843Medicare UPIN