Provider Demographics
NPI:1700880101
Name:WILLARD, RANDALL NORMAN (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:NORMAN
Last Name:WILLARD
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 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-452-1400
Mailing Address - Fax:910-332-1072
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-452-1400
Practice Address - Fax:910-332-1072
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400437207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891368YMedicaid
NCD7960OtherMEDCOST
NCP00311531OtherRAILROAD MEDICARE
SCQ0043GMedicaid
NC1368YOtherBCBS
NCP00311531OtherRAILROAD MEDICARE
NCI13948Medicare UPIN
NC2029986EMedicare PIN