1851567804 NPI number — DR. RANDALL WADE KRUPSAW PH.D.

Table of content: DR. RANDALL WADE KRUPSAW PH.D. (NPI 1851567804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851567804 NPI number — DR. RANDALL WADE KRUPSAW PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUPSAW
Provider First Name:
RANDALL
Provider Middle Name:
WADE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1851567804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8945 N MERIDIAN ST
Provider Second Line Business Mailing Address:
SUITE 125
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260-5387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-816-5600
Provider Business Mailing Address Fax Number:
317-815-5975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8945 N MERIDIAN ST
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260-5387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-816-5600
Provider Business Practice Location Address Fax Number:
317-815-5975
Provider Enumeration Date:
04/30/2008

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: 103TC0700X , with the licence number:  20040117A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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