Healthcare Provider Details

I. General information

NPI: 1922637578
Provider Name (Legal Business Name): RANDY C MICHAEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 08/14/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W DL INGRAM AVENUE BUILDING 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

224 W DL INGRAM AVENUE BUILDING 1408
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO2024-0053
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: