Healthcare Provider Details

I. General information

NPI: 1023019049
Provider Name (Legal Business Name): RANDOLPH W HEISINGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 05/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 W 8TH ST
YANKTON SD
57078-3306
US

IV. Provider business mailing address

1104 W 8TH ST
YANKTON SD
57078-3306
US

V. Phone/Fax

Practice location:
  • Phone: 605-665-7841
  • Fax: 605-665-0546
Mailing address:
  • Phone: 605-665-7841
  • Fax: 605-665-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1066
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: