Provider Demographics
NPI:1902856065
Name:RANDALL, WENDELL LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:LEWIS
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3747
Mailing Address - Country:US
Mailing Address - Phone:336-648-8550
Mailing Address - Fax:336-648-8551
Practice Address - Street 1:956 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3747
Practice Address - Country:US
Practice Address - Phone:336-648-8550
Practice Address - Fax:336-648-8551
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36016207ZP0102X, 208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVF492B944OtherMEDICARE NUMBER
NC70121OtherBCBS INDIVIDUAL
NC89070121Medicaid
NC36016OtherNORTH CAROLINA MEDICAL BOARD MEDICAL LICENSE
NC36016OtherNORTH CAROLINA MEDICAL BOARD MEDICAL LICENSE
NC89070121Medicaid