Active NPI
Randolph Thomas Travis, DMD
- Pediatric Dentistry
- Madisonville, KY
National Provider Identifier
1407862626
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- KY. 5141
- Practice address
- 1400 Pride Avenue
Madisonville, KY 42431-9108 - Phone
- (270) 821-7386
- Fax
- (270) 821-7401
- NPI assigned
- Jul 31, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | KY. 5141 | KY | Primary |
| Pediatric Dentistry | 1223P0221X | INDIANA 12010320A | KY | |
| Pediatric Dentistry | 1223P0221X | OHIO 30.019661 | OH | |
| General Practice Dentistry | 1223G0001X | 5141 | KY |
Addresses
Primary practice location
1400 Pride Avenue
Madisonville, KY 42431-9108
Mailing address
1400 Pride Avenue
Madisonville, KY 42431-9108
Phone (270) 821-7386
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 600-51414 | Medicaid | KY | |
| 45608965 | Other | KY | EPSDT |
| 200265680 A | Medicaid | IN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| INDIANA 12010320A | KY | MD | Pediatric Dentist |
| KY. 5141 | KY | MD | Pediatric Dentist |
| OHIO 30.019661 | OH | MD | Pediatric Dentist |
| 5141 | KY | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154304000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1213228800000",
"number": "1407862626",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1400 PRIDE AVENUE",
"city": "MADISONVILLE",
"state": "KY",
"postal_code": "424319108",
"telephone_number": "270-821-7386",
"fax_number": "270-821-7401"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1400 PRIDE AVENUE",
"city": "MADISONVILLE",
"state": "KY",
"postal_code": "424319108",
"telephone_number": "270-821-7386",
"fax_number": "270-821-7401"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TRAVIS",
"first_name": "RANDOLPH",
"middle_name": "THOMAS",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-31",
"last_updated": "2008-06-12",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "KY",
"license": "KY. 5141",
"primary": true
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "KY",
"license": "INDIANA 12010320A",
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "OH",
"license": "OHIO 30.019661",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "KY",
"license": "5141",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "600-51414",
"state": "KY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "EPSDT",
"identifier": "45608965",
"state": "KY"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200265680 A",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Madisonville, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.