Healthcare Provider Details

I. General information

NPI: 1992783286
Provider Name (Legal Business Name): RANDALL T BASHORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25892 N. JAMES MADISON HWY
NEW CANTON VA
23123-0220
US

IV. Provider business mailing address

PO BOX 220
NEW CANTON VA
23123-0220
US

V. Phone/Fax

Practice location:
  • Phone: 434-581-3271
  • Fax: 434-581-1105
Mailing address:
  • Phone: 434-581-3271
  • Fax: 434-581-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101035538
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: