Healthcare Provider Details

I. General information

NPI: 1245340488
Provider Name (Legal Business Name): RANDALL DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SAGAMORE PKWY W
WEST LAFAYETTE BRA IN
47906-1569
US

IV. Provider business mailing address

124 SAGAMORE PKWY W
WEST LAFAYETTE BRA IN
47906-1569
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-6722
  • Fax: 765-463-0905
Mailing address:
  • Phone: 765-463-6722
  • Fax: 765-463-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number01042716
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000699A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number710013695B
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001017A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01042716
License Number StateIN

VIII. Authorized Official

Name: JOHN K RANDALL
Title or Position: PRESIDENT/OWNER
Credential: RPH,MD
Phone: 765-463-6722