Healthcare Provider Details

I. General information

NPI: 1609080969
Provider Name (Legal Business Name): GURPREET RANDHAWA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 W 15TH ST #202
LIBERAL KS
67901-2285
US

IV. Provider business mailing address

1411 W 15TH ST #202
LIBERAL KS
67901-2285
US

V. Phone/Fax

Practice location:
  • Phone: 620-626-5033
  • Fax: 620-624-7881
Mailing address:
  • Phone: 620-626-5033
  • Fax: 620-624-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0428472
License Number StateKS

VIII. Authorized Official

Name: MRS. JEIVEN RANDHAWA
Title or Position: MANAGER
Credential:
Phone: 620-626-5033