Provider Demographics
NPI:1306897707
Name:RANDALL, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:RANDALL
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 458
Mailing Address - Street 2:
Mailing Address - City:ATKINSON
Mailing Address - State:NE
Mailing Address - Zip Code:68713-0458
Mailing Address - Country:US
Mailing Address - Phone:402-925-2811
Mailing Address - Fax:402-925-2914
Practice Address - Street 1:405 W PEARL ST
Practice Address - Street 2:CLINIC
Practice Address - City:ATKINSON
Practice Address - State:NE
Practice Address - Zip Code:68713-4882
Practice Address - Country:US
Practice Address - Phone:402-925-2811
Practice Address - Fax:402-925-2914
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
089031Medicare ID - Type Unspecified
B67869Medicare UPIN