Healthcare Provider Details

I. General information

NPI: 1548365448
Provider Name (Legal Business Name): R RANDALL SUKMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 S BUSINESS HIGHWAY 65
HOLLISTER MO
65672-5105
US

IV. Provider business mailing address

2331 S BUSINESS HIGHWAY 65
HOLLISTER MO
65672-5105
US

V. Phone/Fax

Practice location:
  • Phone: 417-339-3033
  • Fax: 417-339-9133
Mailing address:
  • Phone: 417-339-3033
  • Fax: 417-339-9133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number109959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: