Healthcare Provider Details

I. General information

NPI: 1679567325
Provider Name (Legal Business Name): RANDALL V LESTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 CHERRY ST SUITE 206, BLDG A
BLUEFIELD WV
24701-3338
US

IV. Provider business mailing address

510 CHERRY ST. SUITE 206, BLDG A
BLUEFIELD WV
24701
US

V. Phone/Fax

Practice location:
  • Phone: 304-327-1888
  • Fax: 304-327-1889
Mailing address:
  • Phone: 304-327-1888
  • Fax: 304-327-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101057487
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01066693A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number12612
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: