Healthcare Provider Details

I. General information

NPI: 1003337908
Provider Name (Legal Business Name): KRISTOPHER WARD RANDALL DO, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL FAMILY BRANCH HEALTH CLINIC 1 CHOME MISUMIMACHI
IWAKUNI YAMAGUCHI
96310
JP

IV. Provider business mailing address

NAVAL FAMILY BRANCH HEALTH CLINIC 1 CHOME MISUMIMACHI
IWAKUNI YAMAGUCHI
96310
JP

V. Phone/Fax

Practice location:
  • Phone: 82-794-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0102205353
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: