Provider Demographics
NPI:1588640312
Name:DODGE, WILLIAM RANDOLPH II
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RANDOLPH
Last Name:DODGE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 AZUL WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-6816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 AZUL WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-6816
Practice Address - Country:US
Practice Address - Phone:301-560-4522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2008-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70260207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine