Provider Demographics
NPI:1659360808
Name:THEILER, RANDY T (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:T
Last Name:THEILER
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 1:451 E BROOKLYN ST
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1595
Mailing Address - Country:US
Mailing Address - Phone:920-849-9375
Mailing Address - Fax:
Practice Address - Street 1:451 E BROOKLYN ST
Practice Address - Street 2:
Practice Address - City:CHILTON
Practice Address - State:WI
Practice Address - Zip Code:53014-1595
Practice Address - Country:US
Practice Address - Phone:920-849-9375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30278000Medicaid
WI30278000Medicaid