1699779272 NPI number — CRAIG RANDALL PARENT DPM

Table of content: CRAIG RANDALL PARENT DPM (NPI 1699779272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699779272 NPI number — CRAIG RANDALL PARENT DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARENT
Provider First Name:
CRAIG
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699779272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/21/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 LAS POSAS RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93010-1501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-383-3668
Provider Business Mailing Address Fax Number:
805-383-3661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 LAS POSAS RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-383-3668
Provider Business Practice Location Address Fax Number:
805-383-3661
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E4710 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E4710 . This is a "MEDICARE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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