Provider Demographics
NPI:1013097278
Name:PLONKA, RANDY JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:JOHN
Last Name:PLONKA
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 1:5979 LAKESHORE
Mailing Address - Street 2:
Mailing Address - City:FT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059
Mailing Address - Country:US
Mailing Address - Phone:810-385-6370
Mailing Address - Fax:810-385-6357
Practice Address - Street 1:5979 LAKESHORE
Practice Address - Street 2:
Practice Address - City:FT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059
Practice Address - Country:US
Practice Address - Phone:810-385-6370
Practice Address - Fax:810-385-6357
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI050787207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4369770Medicaid
A73963Medicare UPIN
MI0760842Medicare PIN