Provider Demographics
NPI:1124023072
Name:LEE, RANDALL A (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:A
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TRAFALGAR SQ
Mailing Address - Street 2:
Mailing Address - City:TRAFALGAR
Mailing Address - State:IN
Mailing Address - Zip Code:46181-9515
Mailing Address - Country:US
Mailing Address - Phone:317-739-4895
Mailing Address - Fax:812-526-4900
Practice Address - Street 1:14 TRAFALGAR SQ
Practice Address - Street 2:
Practice Address - City:TRAFALGAR
Practice Address - State:IN
Practice Address - Zip Code:46181-9515
Practice Address - Country:US
Practice Address - Phone:317-739-4895
Practice Address - Fax:812-526-4900
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100186130AMedicaid
INM400023826Medicare PIN
IN100186130AMedicaid
INM400051293Medicare PIN
INM400051293Medicare PIN