Provider Demographics
NPI:1346504602
Name:FORD, RANDOLPH WILLIAM G (DVM)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:WILLIAM G
Last Name:FORD
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21920 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2034
Mailing Address - Country:US
Mailing Address - Phone:503-665-1109
Mailing Address - Fax:503-666-3664
Practice Address - Street 1:21920 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2034
Practice Address - Country:US
Practice Address - Phone:503-665-1109
Practice Address - Fax:503-666-3664
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4500174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian