Provider Demographics
NPI:1942704507
Name:RANDALL, SAMUEL JOHN
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOHN
Last Name:RANDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 TAUB LOOP
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1608
Mailing Address - Country:US
Mailing Address - Phone:713-798-1750
Mailing Address - Fax:713-798-4693
Practice Address - Street 1:1475 E BELVIDERE RD UNIT 385
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2026
Practice Address - Country:US
Practice Address - Phone:312-694-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT2729207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1146320276Medicaid