Provider Demographics
NPI:1760612444
Name:HERMAN, RANDALL KENNETH DEWITT (MED)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:KENNETH DEWITT
Last Name:HERMAN
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:POINT REYES STATION
Mailing Address - State:CA
Mailing Address - Zip Code:94956-0331
Mailing Address - Country:US
Mailing Address - Phone:415-473-3809
Mailing Address - Fax:415-473-3828
Practice Address - Street 1:100 6TH STREET
Practice Address - Street 2:
Practice Address - City:POINT REYES STATION
Practice Address - State:CA
Practice Address - Zip Code:94956-0331
Practice Address - Country:US
Practice Address - Phone:415-473-3809
Practice Address - Fax:415-473-3828
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program