Organization
RANDALL DERMATOLOGY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN K RANDALL RPH,MD (PRESIDENT/OWNER)
(765) 463-6722
Entity
Organization
Contact information
Practice address
124 SAGAMORE PKWY W, WEST LAFAYETTE BRA, IN 47906-1569
(765) 463-6722
(765) 463-0905
Mailing address
124 SAGAMORE PKWY W, WEST LAFAYETTE BRA, IN 47906-1569
(765) 463-6722
(765) 463-0905
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
01042716
IN
207ND0101X
MOHS-Micrographic Surgery Physician
01042716
IN
363A00000X
Physician Assistant
10000699A
IN
363L00000X
Nurse Practitioner
71001017A
IN
363L00000X
Nurse Practitioner
710013695B
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200207110A
—
IN
Enumeration date
08/30/2006
Last updated
12/19/2024
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