Provider Demographics
NPI:1932849874
Name:RANDALL, DUSTIN JEFF
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JEFF
Last Name:RANDALL
Suffix:
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 1:1700 FRUITLAND DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2989
Mailing Address - Country:US
Mailing Address - Phone:801-645-9584
Mailing Address - Fax:
Practice Address - Street 1:703 N FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1014
Practice Address - Country:US
Practice Address - Phone:954-436-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty