Provider Demographics
NPI:1063439917
Name:JERNIGAN, RANDAL FORD (MD)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:FORD
Last Name:JERNIGAN
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:PO BOX 5471
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5471
Mailing Address - Country:US
Mailing Address - Phone:866-898-7136
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23756207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK5532Medicaid
CO76738787Medicaid
CO76738787Medicaid
C804580Medicare PIN
P00326722Medicare PIN