Provider Demographics
NPI:1699737114
Name:SMITH, RANDALL HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:HOWARD
Last Name:SMITH
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 1:1930 STATE ROUTE 59
Mailing Address - Street 2:SUITE D
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4112
Mailing Address - Country:US
Mailing Address - Phone:330-678-5447
Mailing Address - Fax:330-678-5638
Practice Address - Street 1:1930 STATE ROUTE 59
Practice Address - Street 2:SUITE D
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4112
Practice Address - Country:US
Practice Address - Phone:330-678-5447
Practice Address - Fax:330-678-5638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH045481208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484104Medicaid
OH0484104Medicaid
OH0507204Medicare ID - Type Unspecified