Provider Demographics
NPI:1942259114
Name:MODLIN, RANDOLPH EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:EUGENE
Last Name:MODLIN
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 1:320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-2414
Mailing Address - Country:US
Mailing Address - Phone:304-536-4870
Mailing Address - Fax:
Practice Address - Street 1:320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE SULPHUR SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986-2414
Practice Address - Country:US
Practice Address - Phone:304-536-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30837207RC0000X
WV25813207RC0000X
VA0101255193207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease