Provider Demographics
NPI:1902882046
Name:HIGASHIDA, RANDALL T (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:T
Last Name:HIGASHIDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT LA 23407
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-0001
Mailing Address - Country:US
Mailing Address - Phone:415-353-1869
Mailing Address - Fax:415-353-8606
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:L352
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-353-1869
Practice Address - Fax:415-353-8606
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0026390Medicaid
CAA28299Medicare UPIN
CA00A371110Medicare PIN
CAAZ589ZMedicare PIN