Provider Demographics
NPI:1174625750
Name:MIDOCK, RANDALL L (PHD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:MIDOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 DICK TURPIN COURT
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655
Mailing Address - Country:US
Mailing Address - Phone:540-869-2015
Mailing Address - Fax:
Practice Address - Street 1:801 S LOUDOUN STREET
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-667-5431
Practice Address - Fax:540-667-2655
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0803000079103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA211030OtherBLUE CROSS BLUE SHIELD
VA088289OtherCOMMUNITY HEALTH