Provider Demographics
NPI:1265434112
Name:BJORK, RANDALL J (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:BJORK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:PROVIDER SERVICES
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:611 E DOUGLAS RD STE 305
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1467
Practice Address - Country:US
Practice Address - Phone:574-335-6450
Practice Address - Fax:574-335-0643
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO290182084N0400X
WAMD609878662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01290188Medicaid
CO01290188Medicaid