Provider Demographics
NPI:1689620999
Name:HEISSER, RANDY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:ROBERT
Last Name:HEISSER
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 1:1508 TOMBRAS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2720
Mailing Address - Country:US
Mailing Address - Phone:423-867-4969
Mailing Address - Fax:423-867-4971
Practice Address - Street 1:1508 TOMBRAS AVE
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2720
Practice Address - Country:US
Practice Address - Phone:423-867-4969
Practice Address - Fax:423-867-4971
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4165919OtherBCBS- TN
TNTN0104OtherJOHN DEERE HEALTH
TNF40535OtherHEALTHSPRINGS
TN1515872Medicaid
TNP00207748OtherRAILROAD MEDICARE
TN3092570Medicare PIN
TNTN0104OtherJOHN DEERE HEALTH