Provider Demographics
NPI:1831299429
Name:MACDONALD, RANDOLPH ROBERT (EDD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:ROBERT
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-4044
Mailing Address - Country:US
Mailing Address - Phone:304-725-9645
Mailing Address - Fax:
Practice Address - Street 1:1003 SALLIE LN
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-4044
Practice Address - Country:US
Practice Address - Phone:304-725-9645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0163618000Medicaid
WV0163618000Medicaid