Provider Demographics
NPI:1487604435
Name:SISAM, RANDALL L (DO)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:SISAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:180 KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4541
Mailing Address - Country:US
Mailing Address - Phone:207-872-5529
Mailing Address - Fax:207-872-9219
Practice Address - Street 1:180 KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4540
Practice Address - Country:US
Practice Address - Phone:207-872-5529
Practice Address - Fax:207-872-9219
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MELT06104A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G03551Medicare UPIN