Provider Demographics
NPI:1790752111
Name:DIERKING, RANDALL FREDERICK JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:FREDERICK
Last Name:DIERKING
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7 HART ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3321
Mailing Address - Country:US
Mailing Address - Phone:860-405-0343
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:UNDERSEA MEDICINE
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2324
Practice Address - Country:US
Practice Address - Phone:860-449-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman