Healthcare Provider Details

I. General information

NPI: 1366447864
Provider Name (Legal Business Name): RANDALL PATKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HIGHLAND AVE SUITE 20
SALEM MA
01970-7003
US

IV. Provider business mailing address

400 HIGHLAND AVE SUITE 20
SALEM MA
01970-7003
US

V. Phone/Fax

Practice location:
  • Phone: 978-744-1177
  • Fax: 978-910-0125
Mailing address:
  • Phone: 978-744-1177
  • Fax: 978-910-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number70754
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: