Provider Demographics
NPI:1851471700
Name:NORDYKE, RANDOLPH W (DPM)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:W
Last Name:NORDYKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4080 LOMA VISTA RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1811
Mailing Address - Country:US
Mailing Address - Phone:805-650-8333
Mailing Address - Fax:805-650-8382
Practice Address - Street 1:4080 LOMA VISTA RD
Practice Address - Street 2:SUITE D
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1811
Practice Address - Country:US
Practice Address - Phone:805-650-8333
Practice Address - Fax:805-650-8382
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4245213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4245Medicare ID - Type Unspecified
CAT1929Medicare UPIN