Healthcare Provider Details

I. General information

NPI: 1821076100
Provider Name (Legal Business Name): RANDALL NICOLL PRATT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 GRAINWOOD WAY
SAN DIEGO CA
92131-2283
US

IV. Provider business mailing address

12401 GRAINWOOD WAY
SAN DIEGO CA
92131-2283
US

V. Phone/Fax

Practice location:
  • Phone: 619-458-2673
  • Fax:
Mailing address:
  • Phone: 619-458-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG33734
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberG33734
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG33734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: