Provider Demographics
NPI:1265443550
Name:FEDRO, RANDALL C (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:C
Last Name:FEDRO
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 1:4211 MONARCH WAY 100
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2540
Mailing Address - Country:US
Mailing Address - Phone:757-738-1400
Mailing Address - Fax:757-489-3092
Practice Address - Street 1:1232 PERIMETER PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5924
Practice Address - Country:US
Practice Address - Phone:757-425-8590
Practice Address - Fax:757-422-5107
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB08911Medicare UPIN
VA021631B09Medicare PIN
VA016798C10Medicare PIN