Provider Demographics
NPI:1104806579
Name:FEARING, RANDY J (DC)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:J
Last Name:FEARING
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 NW 23RD AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6570
Mailing Address - Country:US
Mailing Address - Phone:352-377-5158
Mailing Address - Fax:352-377-4303
Practice Address - Street 1:4509 NW 23RD AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6570
Practice Address - Country:US
Practice Address - Phone:352-377-5158
Practice Address - Fax:352-377-4303
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2440111N00000X, 111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050318500Medicaid
FL89904OtherBLUE CROSS BLUE SHIELD FL
FL89904Medicare ID - Type Unspecified
FL89904OtherBLUE CROSS BLUE SHIELD FL