Provider Demographics
NPI:1730592320
Name:MAHARRY, RANDALL
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:MAHARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1950 REDTAIL HAWK DR
Practice Address - Street 2:
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-9780
Practice Address - Country:US
Practice Address - Phone:970-586-9230
Practice Address - Fax:970-577-3464
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODRP0000555207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology