Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 01042716 | IN |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 01042716 | IN |
N | 207ND0900X | Dermatopathologist | 01042716 | IN |
NPI | 1326076530 |
---|---|
Provider Name | Dr. John K Randall |
First Address | West Lafayette, IN 47906-1569 |
Second Address | West Lafayette, IN 47906-1569 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2006 |
Last Update Date | 22/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000092649 | BCBS (01) | IN |
01042716 | LICENSE (01) | IN |
01042716B | CSR (01) | IN |
100415730A | (05) | IN |
200207110A | (05) | IN |
BR1531385 | DEA (01) | |
F-25912 | (02) | IN |