Provider Demographics
NPI:1023191715
Name:RANDALL, TODD VINCENT (DPT)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:VINCENT
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 DAYTON XENIA RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6481
Mailing Address - Country:US
Mailing Address - Phone:937-426-5555
Mailing Address - Fax:937-426-5556
Practice Address - Street 1:3224 DAYTON XENIA RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6481
Practice Address - Country:US
Practice Address - Phone:937-426-5555
Practice Address - Fax:937-426-5556
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000360867OtherANTHEM PIN
OH0108341Medicaid
OH000000360867OtherANTHEM PIN
OH0108341Medicaid