Provider Demographics
NPI:1962486712
Name:COUSINS, RANDALL JON (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JON
Last Name:COUSINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:JON
Other - Last Name:COUSINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2000 PLYMOUTH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2366
Mailing Address - Country:US
Mailing Address - Phone:763-581-5250
Mailing Address - Fax:763-581-5257
Practice Address - Street 1:2000 PLYMOUTH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2366
Practice Address - Country:US
Practice Address - Phone:763-581-5250
Practice Address - Fax:763-581-5257
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN631570400Medicaid
MN089005706Medicare ID - Type Unspecified
MN631570400Medicaid