Provider Demographics
NPI:1699732115
Name:SAMPLES, RANDALL GARY (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:GARY
Last Name:SAMPLES
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:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084
Mailing Address - Country:US
Mailing Address - Phone:540-674-9359
Mailing Address - Fax:540-674-1825
Practice Address - Street 1:5562 COUGAR TRAIL RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084
Practice Address - Country:US
Practice Address - Phone:540-674-9359
Practice Address - Fax:540-674-1825
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033704208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A96833Medicare UPIN