Provider Demographics
NPI:1801859574
Name:VISSER, RANDY DALE (DO)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DALE
Last Name:VISSER
Suffix:
Gender:M
Credentials:DO
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 520
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0111
Mailing Address - Country:US
Mailing Address - Phone:541-420-9482
Mailing Address - Fax:541-323-3794
Practice Address - Street 1:4282 SW 43RD ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-6976
Practice Address - Country:US
Practice Address - Phone:541-420-9482
Practice Address - Fax:541-323-3794
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG25695Medicare UPIN
OR115997Medicare PIN