Provider Demographics
NPI:1649291980
Name:DWENGER, RANDALL R (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:DWENGER
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 1:30 CEDAR CREST
Mailing Address - Street 2:PO BOX 443
Mailing Address - City:SALISBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06068-0443
Mailing Address - Country:US
Mailing Address - Phone:917-513-7438
Mailing Address - Fax:888-690-2727
Practice Address - Street 1:187 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2544
Practice Address - Country:US
Practice Address - Phone:860-824-1397
Practice Address - Fax:888-690-2727
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1832972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry