Provider Demographics
NPI:1720498389
Name:RANDY D VISSER DO PC
Entity Type:Organization
Organization Name:RANDY D VISSER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:VISSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-420-9482
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0111
Mailing Address - Country:US
Mailing Address - Phone:541-420-9482
Mailing Address - Fax:541-323-3794
Practice Address - Street 1:4282 SW 43RD ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-6976
Practice Address - Country:US
Practice Address - Phone:541-420-9482
Practice Address - Fax:541-323-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty