Provider Demographics
NPI:1679576730
Name:SHUE, RANDALL G (DO)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:G
Last Name:SHUE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4055 E OLYMPIC BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-3345
Mailing Address - Country:US
Mailing Address - Phone:323-268-3491
Mailing Address - Fax:323-264-8406
Practice Address - Street 1:4055 E OLYMPIC BLVD
Practice Address - Street 2:STE 210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3345
Practice Address - Country:US
Practice Address - Phone:323-268-3491
Practice Address - Fax:323-264-8406
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A5142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX51420Medicaid
CA00AX51422Medicaid
CA20A51420Medicare ID - Type Unspecified
20A51422Medicare ID - Type Unspecified
CA00AX51422Medicaid