Provider Demographics
NPI:1952385114
Name:REISTER, RANDOLPH J (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:J
Last Name:REISTER
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 1:1202 9TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1210
Mailing Address - Country:US
Mailing Address - Phone:605-845-3582
Mailing Address - Fax:
Practice Address - Street 1:710 DIVISION ST S
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2468
Practice Address - Country:US
Practice Address - Phone:507-646-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5242207R00000X
MN102423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6004640Medicaid
41438Medicare ID - Type Unspecified
H93432Medicare UPIN