Provider Demographics
NPI:1538149778
Name:LARGE, RANDY S (DO)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:LARGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-3649
Mailing Address - Fax:
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-3649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-34380207L00000X
AZ3086207L00000X
MO2010000744207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81882556Medicaid
CO81882556Medicaid
COG40570Medicare UPIN