Healthcare Provider Details

I. General information

NPI: 1881915346
Provider Name (Legal Business Name): WILLIAM THOBURN RANDAZZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HIGHGATE W
AUGUSTA GA
30909-3109
US

IV. Provider business mailing address

22100 BOTHELL EVERETT HWY
BOTHELL WA
98021-8431
US

V. Phone/Fax

Practice location:
  • Phone: 208-416-2932
  • Fax: 855-673-9190
Mailing address:
  • Phone: 208-416-2932
  • Fax: 855-673-9190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101257809
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number081756
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: