Provider Demographics
NPI:1740217603
Name:BURR, RANDALL D (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:D
Last Name:BURR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1618 S. MILLENNIUM WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6457
Mailing Address - Country:US
Mailing Address - Phone:208-884-3376
Mailing Address - Fax:208-884-0858
Practice Address - Street 1:1618 S. MILLENNIUM WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6457
Practice Address - Country:US
Practice Address - Phone:208-884-3376
Practice Address - Fax:208-884-0858
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM5986207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003412200Medicaid
ID1125990Medicare ID - Type Unspecified
ID003412200Medicaid