Provider Demographics
NPI:1992700520
Name:RANDOLPH, WALTER WATSON III (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:WATSON
Last Name:RANDOLPH
Suffix:III
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 1:1417 KADERLY ST NW
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-1242
Mailing Address - Country:US
Mailing Address - Phone:330-602-5678
Mailing Address - Fax:330-602-9604
Practice Address - Street 1:1417 KADERLY ST NW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-1242
Practice Address - Country:US
Practice Address - Phone:330-602-5678
Practice Address - Fax:330-602-9604
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071310R207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2127157Medicaid
G98705Medicare UPIN
OHRA0883431Medicare ID - Type Unspecified