Provider Demographics
NPI:1750554218
Name:RANDALL, KYLE (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:RANDALL
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 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 RICHLAND MALL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3802
Practice Address - Country:US
Practice Address - Phone:419-709-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.124114207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197144Medicaid