Provider Demographics
NPI:1043294507
Name:FALK, RANDOLPH JAY (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:JAY
Last Name:FALK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11030 VALLEY MALL
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2617
Mailing Address - Country:US
Mailing Address - Phone:626-444-4545
Mailing Address - Fax:626-444-8989
Practice Address - Street 1:11030 VALLEY MALL
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2617
Practice Address - Country:US
Practice Address - Phone:626-444-4545
Practice Address - Fax:626-444-8989
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41643207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC41643OtherCA MEDICAL LICENSE #
CA00C416430Medicaid
95-4509955OtherEIN
CA00C416430Medicaid
CA0752460001Medicare NSC