Provider Demographics
NPI:1699934760
Name:RANDALL WEISSBUCH MD INC
Entity type:Organization
Organization Name:RANDALL WEISSBUCH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:WEISSBUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-277-5510
Mailing Address - Street 1:2736 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5747
Mailing Address - Country:US
Mailing Address - Phone:323-277-5510
Mailing Address - Fax:323-277-5530
Practice Address - Street 1:2736 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5747
Practice Address - Country:US
Practice Address - Phone:323-277-5510
Practice Address - Fax:323-277-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA232852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A232850Medicaid