1336155944 NPI number — DR. RANDALL ELLIOTT DALTON MD

Table of content: DR. RANDALL ELLIOTT DALTON MD (NPI 1336155944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336155944 NPI number — DR. RANDALL ELLIOTT DALTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALTON
Provider First Name:
RANDALL
Provider Middle Name:
ELLIOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1336155944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 HARDIN LN
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42503-3818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-451-3890
Provider Business Mailing Address Fax Number:
606-451-3896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 HARDIN LANE
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-3890
Provider Business Practice Location Address Fax Number:
606-451-3896
Provider Enumeration Date:
08/01/2006

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: 207Y00000X , with the licence number:  43128 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2445705 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35083245 . This is a "LICENSE #" identifier . This identifiers is of the category "OTHER".




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