Individual
DR. JOHN K RANDALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RPH, MD
Contact information
Practice address
124 SAGAMORE PKWY W, WEST LAFAYETTE, IN 47906-1569
(765) 463-6722
(765) 463-0905
Mailing address
124 SAGAMORE PKWY W, WEST LAFAYETTE, IN 47906-1569
(765) 463-6722
(765) 463-0905
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
01042716
IN
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
01042716
IN
207ND0900X
Dermatopathology Physician
01042716
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000092649
BCBS
IN
01
—
01042716
LICENSE
IN
01
—
01042716B
CSR
IN
05
—
100415730A
—
IN
05
—
200207110A
—
IN
Enumeration date
06/28/2006
Last updated
12/19/2024
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