Provider Demographics
NPI:1609861996
Name:BRODNIK, RANDY M (DO FACOG)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:M
Last Name:BRODNIK
Suffix:
Gender:M
Credentials:DO FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 COURTHOUSE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2450
Mailing Address - Country:US
Mailing Address - Phone:304-327-0531
Mailing Address - Fax:304-324-0548
Practice Address - Street 1:150 COURTHOUSE RD STE 202
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2450
Practice Address - Country:US
Practice Address - Phone:304-327-0531
Practice Address - Fax:304-324-0548
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1566207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6210970OtherVIRGINIA MEDICAID
WV0093390000Medicaid
WVBR0784454Medicare ID - Type Unspecified
VA6210970OtherVIRGINIA MEDICAID