Provider Demographics
NPI:1720114226
Name:LANFORD, RANDOLPH EWING (MD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:EWING
Last Name:LANFORD
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 458
Mailing Address - Street 2:
Mailing Address - City:FORK UNION
Mailing Address - State:VA
Mailing Address - Zip Code:23055
Mailing Address - Country:US
Mailing Address - Phone:434-842-3244
Mailing Address - Fax:434-842-1110
Practice Address - Street 1:4064 JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:FORK UNION
Practice Address - State:VA
Practice Address - Zip Code:23055
Practice Address - Country:US
Practice Address - Phone:434-842-3244
Practice Address - Fax:434-842-1110
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032081207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005615151Medicaid
VA005615151Medicaid
B06283Medicare UPIN