Provider Demographics
NPI:1720046295
Name:RANDALL, JEFFREY BLAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BLAINE
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:20055 LAKE CHABOT RD
Mailing Address - Street 2:# 110
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546
Mailing Address - Country:US
Mailing Address - Phone:510-886-3138
Mailing Address - Fax:510-373-1616
Practice Address - Street 1:20055 LAKE CHABOT RD
Practice Address - Street 2:# 110
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:510-886-3138
Practice Address - Fax:510-373-1616
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG68717207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G687170Medicaid
00G687170Medicare ID - Type Unspecified
CA00G687170Medicaid