Provider Demographics
NPI:1144351149
Name:AYBAR, RANDALL I (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:I
Last Name:AYBAR
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 1:500 LINCOLN PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6410
Mailing Address - Country:US
Mailing Address - Phone:937-531-5020
Mailing Address - Fax:937-298-4385
Practice Address - Street 1:500 LINCOLN PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6410
Practice Address - Country:US
Practice Address - Phone:937-531-5020
Practice Address - Fax:937-298-4385
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.137497207R00000X
CAG81088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0369384Medicaid