Basic Information
| Provider Information | |||||||||
| NPI: | 1023496957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IP | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6355 S BUFFALO DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891132133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 SIENA HEIGHTS DR STE 331 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024070110 | ||||||||
| FaxNumber: | 7024070133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2015 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101021664 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | DO2923 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | DO2923 | 01 | NV | STATE LICENSE | OTHER |