Provider Demographics
NPI:1336155944
Name:DALTON, RANDALL ELLIOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ELLIOTT
Last Name:DALTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HARDIN LN
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3818
Mailing Address - Country:US
Mailing Address - Phone:606-451-3890
Mailing Address - Fax:606-451-3896
Practice Address - Street 1:110 HARDIN LANE
Practice Address - Street 2:SUITE 10
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3818
Practice Address - Country:US
Practice Address - Phone:606-451-3890
Practice Address - Fax:606-451-3896
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43128207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2445705Medicaid
35083245OtherLICENSE #
35083245OtherLICENSE #
KY00971001Medicare PIN
B08701Medicare UPIN
OH2445705Medicaid