Provider Demographics
NPI:1649684952
Name:DAVIS, RANDAL (DO)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12780 WATERFORD LAKES PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4501
Mailing Address - Country:US
Mailing Address - Phone:407-384-1053
Mailing Address - Fax:407-277-8168
Practice Address - Street 1:12780 WATERFORD LAKES PKWY STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4501
Practice Address - Country:US
Practice Address - Phone:407-384-1053
Practice Address - Fax:407-277-8168
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13584207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherMEDICARE