Provider Demographics
NPI:1932646650
Name:RANDALL, CHRISTOPHER DAVID JR
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:RANDALL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 LUCY GRADE ROAD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-796-5444
Mailing Address - Fax:
Practice Address - Street 1:1017 LUCY GRADE RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-8075
Practice Address - Country:US
Practice Address - Phone:334-796-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8151510390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program