Provider Demographics
NPI:1700974904
Name:RANDALL, JASON THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JASON
Other - Middle Name:T
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:454 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3563
Mailing Address - Country:US
Mailing Address - Phone:334-613-9000
Mailing Address - Fax:334-532-0056
Practice Address - Street 1:454 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-613-9000
Practice Address - Fax:334-532-0056
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.27730207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL111355Medicaid
AL111923Medicaid
5149399OtherBCBS
AL111912Medicaid
AL111355Medicaid