Provider Demographics
NPI:1558469478
Name:MAHNESMITH, RANDOLPH C (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:C
Last Name:MAHNESMITH
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 1:9 S MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2333
Mailing Address - Country:US
Mailing Address - Phone:540-932-5577
Mailing Address - Fax:540-932-5588
Practice Address - Street 1:9 S MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2333
Practice Address - Country:US
Practice Address - Phone:540-932-5577
Practice Address - Fax:540-932-5588
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029849207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6200401Medicaid
B10178Medicare UPIN