Provider Demographics
NPI:1780898239
Name:BROWN, RANDALL SIMPSON (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:SIMPSON
Last Name:BROWN
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 1:3685 CHRIS AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-9774
Mailing Address - Country:US
Mailing Address - Phone:270-724-1320
Mailing Address - Fax:
Practice Address - Street 1:1413 N ELM ST
Practice Address - Street 2:SUITE 204
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2768
Practice Address - Country:US
Practice Address - Phone:270-826-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC64720Medicare UPIN