Randall Dermatology, PC
Organization Active NPI Dermatology Physician · West Lafayette Bra, IN
NPI 1245340488 · NPPES record last updated Dec 19, 2024
Key facts
- NPI
- 1245340488
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dermatology Physician 207N00000X
- License
- 01042716 (IN)
- Legal business name
- RANDALL DERMATOLOGY, PC
- Practice address
- 124 Sagamore Pkwy W
West Lafayette Bra, IN 47906-1569 - Phone
- (765) 463-6722
- Fax
- (765) 463-0905
- NPI assigned
- Aug 30, 2006
- Organization subpart
- No
Authorized official
- Name
- John K Randall, RPH,MD
- Title
- President/Owner
- Phone
- (765) 463-6722
Practitioners 12
-
Stephanie L. Davitto, N.P.
-
Phillip T Deturk, NP
-
Katherine Kay Lanting, APRN
-
Mark Alan Manning, DNP
-
John K Randall, RPH, MD
-
Shelley L Velickoff, A.N.P.
-
Laura L Wavra, NP
-
Nicole M Sherer, ARNP
-
Holly N Howe, NURSE PRACTITIONER
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 15D0910366 | Randall Dermatology PC | Compliance | Jan 29, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070227000078 | IN | Part B Supplier - Clinic/Group Practice | 3678675329 |
Receives reassigned benefits from 11 practitioners Practice locations: West Lafayette, IN; Williamsport, IN; Westfield, IN; Terre Haute, IN; Monticello, IN; Kokomo, IN; Frankfort, IN; Rensselaer, IN |
National Provider Directory
Locations
1351 S Jackson St
Frankfort, IN 46041
Phone (765) 452-8602
620 S Berkley Rd
Kokomo, IN 46901
Phone (317) 457-8291
1201 N McKinley Ave
Rensselaer, IN 47978
Phone (219) 866-7124
124 Sagamore Pkwy W
West Lafayette, IN 47906
Phone (765) 463-6722
201 N Union St
Westfield, IN 46074
Phone (317) 776-0760
616 E 13th St
Winamac, IN 46996
Phone (574) 946-2100
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician |
207N00000X | 01042716 | IN | Yes |
| MOHS-Micrographic Surgery Physician |
207ND0101X | 01042716 | IN | |
| Physician Assistant |
363A00000X | 10000699A | IN | |
| Nurse Practitioner |
363L00000X | 710013695B | IN | |
| Nurse Practitioner |
363L00000X | 71001017A | IN |
Addresses
Primary practice location
124 Sagamore Pkwy W
West Lafayette Bra, IN 47906-1569
Mailing address
124 Sagamore Pkwy W
West Lafayette Bra, IN 47906-1569
Phone (765) 463-6722
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200207110A | Medicaid | IN |
Other providers in West Lafayette Bra, IN
- Malissa K Crowe, LLC
- Thomas Bruce McHenry
- Joyce Lynn Micon
- Barbara Emma Nolan
- Sivaprasad Parnam
- Barbara Ann Salmon
- Helen Therese Seifert
- Nancy J Shook
- Sigma Medical Group
- Jenny Asuncion Sison
All providers in West Lafayette Bra, IN · Dermatology Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 19, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.