Provider Demographics
NPI:1760457980
Name:SMITH, RANDALL S (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
Last Name:SMITH
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 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:969 LAKELAND DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4699
Practice Address - Country:US
Practice Address - Phone:601-200-3840
Practice Address - Fax:601-200-8801
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13000207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05774275Medicaid
MS981416OtherWESTERN OHIO HEALTHCARE
MS4227432OtherAETNA
MSP00305343OtherMEDICARE RR
MSP00305343OtherMEDICARE RR
MS4227432OtherAETNA