Provider Demographics
NPI:1528085347
Name:PROFFITT, RANDY DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:DOUGLAS
Last Name:PROFFITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RANDY
Other - Middle Name:DOUGLAS
Other - Last Name:PROFFITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:740 HILLCREST RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3924
Mailing Address - Country:US
Mailing Address - Phone:251-607-0300
Mailing Address - Fax:251-607-0377
Practice Address - Street 1:740 HILLCREST RD
Practice Address - Street 2:SUITE C
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-3924
Practice Address - Country:US
Practice Address - Phone:251-607-0300
Practice Address - Fax:251-607-0377
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL164022086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE37138Medicare UPIN