Provider Demographics
NPI:1730300906
Name:WHITE, RANDY ALLEN (PROVIDER)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:ALLEN
Last Name:WHITE
Suffix:
Gender:M
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WEST THIRD STREEET
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:45612
Mailing Address - Country:US
Mailing Address - Phone:740-634-2495
Mailing Address - Fax:
Practice Address - Street 1:212 WEST THIRD STREEET
Practice Address - Street 2:212 WEST THIRD STREET
Practice Address - City:BAINBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:45612
Practice Address - Country:US
Practice Address - Phone:740-634-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2316621302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization