Healthcare Provider Details

I. General information

NPI: 1992700520
Provider Name (Legal Business Name): WALTER WATSON RANDOLPH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 KADERLY ST NW
NEW PHILADELPHIA OH
44663-1242
US

IV. Provider business mailing address

1417 KADERLY ST NW
NEW PHILADELPHIA OH
44663-1242
US

V. Phone/Fax

Practice location:
  • Phone: 330-602-5678
  • Fax: 330-602-9604
Mailing address:
  • Phone: 330-602-5678
  • Fax: 330-602-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35071310R
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: