Provider Demographics
NPI:1851355630
Name:RANDALL, WILLIAM JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOHN
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:25 MERCHANT STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3740
Mailing Address - Country:US
Mailing Address - Phone:513-533-6507
Mailing Address - Fax:513-645-9767
Practice Address - Street 1:1900 COMPOSITE DRIVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420-1475
Practice Address - Country:US
Practice Address - Phone:937-293-8419
Practice Address - Fax:937-293-1545
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2015-07-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35.059106 R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0827967Medicaid
P00049048Medicare PIN
OH0827967Medicaid
OHE86939Medicare UPIN