Provider Demographics
NPI:1811061328
Name:RANDALL, KAREN A (DO)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:RANDALL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2745
Mailing Address - Country:US
Mailing Address - Phone:719-584-4306
Mailing Address - Fax:719-595-7886
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4306
Practice Address - Fax:719-595-7886
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010551207Q00000X, 207P00000X
CODR.0051971207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010H262530OtherBLUE CROSS-BLUE CROSS
MI327179611Medicaid
KR010551OtherCOMMERCIAL-COMMERCIAL NUMBER
KR010551OtherCHAMPUS-CHAMPUS
010H262530OtherBLUE CROSS-BLUE CROSS
KR010551OtherCHAMPUS-CHAMPUS