Provider Demographics
NPI:1083692453
Name:CALICOTT, RANDY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:WAYNE
Last Name:CALICOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000741207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36495OtherPARTNERS
NC89126RJMedicaid
NC126RJOtherBLUE CROSS
NC5069608OtherAETNA
WV9801180000Medicaid
NC98162OtherMEDCOST
050086124OtherRR MEDICARE
SCQ0074CMedicaid
VA7300263Medicaid
VA7300263Medicaid
NC89126RJMedicaid