Provider Demographics
NPI:1922044437
Name:JACK, RANDALL ELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ELLIS
Last Name:JACK
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 1:635 INNOVATION DR STE 300
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2215
Mailing Address - Country:US
Mailing Address - Phone:775-329-6241
Mailing Address - Fax:775-329-4921
Practice Address - Street 1:635 INNOVATION DR STE 300
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2215
Practice Address - Country:US
Practice Address - Phone:775-329-6241
Practice Address - Fax:775-329-4921
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13040207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI14252Medicare UPIN
TN3896576Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER