Provider Demographics
NPI:1962438630
Name:LONGENECKER, RANDALL L (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:LONGENECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4879 US HIGHWAY 68 S
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-9525
Mailing Address - Country:US
Mailing Address - Phone:937-599-1411
Mailing Address - Fax:937-465-9945
Practice Address - Street 1:4879 US HIGHWAY 68 S
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357-9525
Practice Address - Country:US
Practice Address - Phone:937-599-1411
Practice Address - Fax:937-465-9945
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047479207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0487147Medicaid
OHA15091Medicare UPIN
OHLO0511352Medicare ID - Type Unspecified