Provider Demographics
NPI:1255376240
Name:RANDALL, MILTON GREGORY (PT)
Entity type:Individual
Prefix:
First Name:MILTON
Middle Name:GREGORY
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:M
Other - Middle Name:GREGOR
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-0457
Mailing Address - Country:US
Mailing Address - Phone:928-207-6873
Mailing Address - Fax:866-762-2534
Practice Address - Street 1:5171 CUB LAKE RD.
Practice Address - Street 2:SUITE C 360
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7823
Practice Address - Country:US
Practice Address - Phone:928-537-0248
Practice Address - Fax:928-537-0251
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6094225100000X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ106053Medicare PIN