Provider Demographics
NPI:1295779114
Name:WENDT, RANDALL J (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:WENDT
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 1:40 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9406
Mailing Address - Country:US
Mailing Address - Phone:803-408-3262
Mailing Address - Fax:
Practice Address - Street 1:8121 MADISON BLVD
Practice Address - Street 2:STE. 101-A
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2080
Practice Address - Country:US
Practice Address - Phone:256-325-6499
Practice Address - Fax:256-325-3195
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24803207V00000X
ALMD.13299207Q00000X
AL13299207V00000X
SC14718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200078790AMedicaid
C75086Medicare UPIN
OK247612503Medicare PIN