Healthcare Provider Details

I. General information

NPI: 1548473069
Provider Name (Legal Business Name): RANDALL RASMUSSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 BIRCHWOOD DR
MORAGA CA
94556-2302
US

IV. Provider business mailing address

251 BIRCHWOOD DR
MORAGA CA
94556-2302
US

V. Phone/Fax

Practice location:
  • Phone: 847-388-2065
  • Fax: 866-720-9740
Mailing address:
  • Phone: 847-388-2065
  • Fax: 866-720-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG32691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: