Provider Demographics
NPI:1710976535
Name:RANDALL, DAVID R (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 LAKE OTIS PKWY STE 312
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5231
Mailing Address - Country:US
Mailing Address - Phone:907-569-3668
Mailing Address - Fax:907-569-3669
Practice Address - Street 1:4100 LAKE OTIS PKY STE 312
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:918-458-7672
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK246213E00000X
AK7269213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8EZ37WMedicare ID - Type Unspecified
U96766Medicare UPIN