Provider Demographics
NPI:1972614774
Name:WARREN, RANDY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
Last Name:WARREN
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 1:1101 JOHNSON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1893
Mailing Address - Country:US
Mailing Address - Phone:843-477-0177
Mailing Address - Fax:
Practice Address - Street 1:1101 JOHNSON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1893
Practice Address - Country:US
Practice Address - Phone:843-477-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV218272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV381002129Medicaid
WV002006862OtherBLUE CROSS/BLUE SHIELD
WVWA4162851Medicare PIN
WV381002129Medicaid