Provider Demographics
NPI:1184618027
Name:COLUCCI, RANDALL A (DO)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:A
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 HOSPITAL DR
Mailing Address - Street 2:SUITE 200, CASTROP CENTER
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2857
Mailing Address - Country:US
Mailing Address - Phone:740-566-4880
Mailing Address - Fax:740-566-4881
Practice Address - Street 1:75 HOSPITAL DR
Practice Address - Street 2:SUITE 200, CASTROP CENTER
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2857
Practice Address - Country:US
Practice Address - Phone:740-566-4880
Practice Address - Fax:740-566-4881
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2357239Medicaid
4089345Medicare PIN