Basic Information
| Provider Information | |||||||||
| NPI: | 1649684952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RANDAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216371595 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 7227 N US HIGHWAY 1 STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORT ST JOHN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216371595 | ||||||||
| FaxNumber: | 3216371596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS13584 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | MEDICARE | OTHER |