Basic Information
| Provider Information | |||||||||
| NPI: | 1265415392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RANDEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15623 S 16TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850488632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804604525 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 W BETHANY HOME RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850152443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022490212 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2484 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | AW1436 | 01 | AZ | HEALTHNET - GROUP # | OTHER | 453051001 | 01 | AZ | GROUP HEALTH - GROUP # | OTHER | 860373636 | 01 | AZ | HUMANA - GROUP # | OTHER | AZ0728670 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | 078817 | 05 | AZ | MEDICAID | 3981220 | 01 | AZ | EVERCARE - GROUP # | OTHER |