Basic Information
| Provider Information | |||||||||
| NPI: | 1073566717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 Y ST STE 3800 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167345885 | ||||||||
| FaxNumber: | 9167347904 | ||||||||
| Practice Location | |||||||||
| Address1: | 4860 Y ST STE 1700 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343398 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 360087-1205 | UT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 2086X0206X | 360087-1205 | UT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | G78312 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 207X00000X | G78312 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | D2579 | 05 | UT | MEDICAID |