Provider Demographics
NPI:1396791455
Name:RIGDON, RANDALL (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:RIGDON
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:PO BOX 561600
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-434-4656
Mailing Address - Fax:321-259-5130
Practice Address - Street 1:255 BORMAN DR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3486
Practice Address - Country:US
Practice Address - Phone:321-434-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66873Medicare UPIN