Healthcare Provider Details

I. General information

NPI: 1174625750
Provider Name (Legal Business Name): RANDALL L MIDOCK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S LOUDOUN STREET
WINCHESTER VA
22601
US

IV. Provider business mailing address

102 DICK TURPIN COURT
STEPHENS CITY VA
22655
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-5431
  • Fax: 540-667-2655
Mailing address:
  • Phone: 540-869-2015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0803000079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: