Provider Demographics
NPI:1215991518
Name:SCHULTZ, RANDOLPH (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:SCHULTZ
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 1:6488 E MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7310
Mailing Address - Country:US
Mailing Address - Phone:614-860-8080
Mailing Address - Fax:614-860-8061
Practice Address - Street 1:6488 E MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7310
Practice Address - Country:US
Practice Address - Phone:614-860-8080
Practice Address - Fax:614-860-8061
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-067280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0224671Medicaid
OH0224671Medicaid