Provider Demographics
NPI:1548473069
Name:RASMUSSEN, RANDALL (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:RASMUSSEN
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 1:251 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-2302
Mailing Address - Country:US
Mailing Address - Phone:847-388-2065
Mailing Address - Fax:866-720-9740
Practice Address - Street 1:251 BIRCHWOOD DR
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-2302
Practice Address - Country:US
Practice Address - Phone:847-388-2065
Practice Address - Fax:866-720-9740
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32691174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG32691Medicare ID - Type Unspecified