Provider Demographics
NPI:1003839135
Name:RANDOLPH, PAMELA JOY (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JOY
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 DANBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897
Mailing Address - Country:US
Mailing Address - Phone:203-852-2270
Mailing Address - Fax:203-899-5027
Practice Address - Street 1:249 DANBURY ROAD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897
Practice Address - Country:US
Practice Address - Phone:203-852-2270
Practice Address - Fax:203-899-5027
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028839207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001288390Medicaid
CT460000079Medicare PIN
CTE46914Medicare UPIN