Provider Demographics
NPI:1407827454
Name:ANDERSON, RANDOLPH VERITY (DPM)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:VERITY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 15TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4500
Mailing Address - Country:US
Mailing Address - Phone:360-424-0002
Mailing Address - Fax:360-424-0021
Practice Address - Street 1:120 S 15TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4500
Practice Address - Country:US
Practice Address - Phone:360-424-0002
Practice Address - Fax:360-424-0021
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000455213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB38381Medicare ID - Type Unspecified
WAU21582Medicare UPIN