Provider Demographics
NPI:1245793728
Name:RANDALL, GRANT JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:JEFFREY
Last Name:RANDALL
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 1:601 NW OBRIEN RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-1806
Mailing Address - Country:US
Mailing Address - Phone:816-287-1528
Mailing Address - Fax:343-503-0640
Practice Address - Street 1:601 NW OBRIEN RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-1806
Practice Address - Country:US
Practice Address - Phone:816-287-1528
Practice Address - Fax:343-503-0640
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024001206207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology