Provider Demographics
NPI:1215955885
Name:MARTIN, RANDALL LEE (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEE
Last Name:MARTIN
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 1:22187 SE LAFAYETTE HWY
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97114-8818
Mailing Address - Country:US
Mailing Address - Phone:503-868-7770
Mailing Address - Fax:
Practice Address - Street 1:204 MCCOLLUM DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070
Practice Address - Country:US
Practice Address - Phone:307-745-6065
Practice Address - Fax:307-745-4936
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14891207L00000X
WYTL1962207L00000X
WA60771584207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR176917Medicaid
IN200948040Medicaid
D38905Medicare UPIN
D38505Medicare UPIN
OR00BHVPRAMedicare ID - Type Unspecified
IN940070H3Medicare PIN