Provider Demographics
NPI:1316313133
Name:DODGE, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 MILL STREAM LN
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4222
Mailing Address - Country:US
Mailing Address - Phone:772-925-9667
Mailing Address - Fax:
Practice Address - Street 1:911 MILL STREAM LN
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4222
Practice Address - Country:US
Practice Address - Phone:772-925-9667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601877172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker