Provider Demographics
NPI:1306133863
Name:COLVIN, RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:COLVIN
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 1:70067 SUNNY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MI
Mailing Address - Zip Code:48062-5561
Mailing Address - Country:US
Mailing Address - Phone:248-548-9860
Mailing Address - Fax:
Practice Address - Street 1:27483 DEQUINDRE RD STE 303
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-5715
Practice Address - Country:US
Practice Address - Phone:248-548-9860
Practice Address - Fax:248-548-6278
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2849652Medicaid
MI0N58330016Medicare PIN