Provider Demographics
NPI:1891929147
Name:CROSS, RANDALL JOE JR (IDMT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JOE
Last Name:CROSS
Suffix:JR
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 36 BOX 207
Mailing Address - Street 2:UNIT 4820 BLDG 476
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09456-0207
Mailing Address - Country:US
Mailing Address - Phone:0128-571-4347
Mailing Address - Fax:
Practice Address - Street 1:420 ABS/SG BLDG 476
Practice Address - Street 2:UNIT 4820
Practice Address - City:RAF FAIRFORD
Practice Address - State:UNITED KINGDOM
Practice Address - Zip Code:GL7 4DL
Practice Address - Country:GB
Practice Address - Phone:0128-571-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians