Individual
DR. RANDALL LOUIS MCKISSACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
999 MAR WALT DR, FORT WALTON BEACH, FL 32547-6758
(850) 863-8269
(850) 862-7965
Mailing address
1005 MAR WALT DRIVE, FORT WALTON BEACH, FL 32547-6707
(850) 863-8269
(850) 862-7965
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
ME96715
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
277632400
—
FL
Enumeration date
12/09/2005
Last updated
11/12/2020
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