Provider Demographics
NPI:1093739708
Name:RANDOLPH, AMELIA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:
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 1:1001 GALAXY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5725
Mailing Address - Country:US
Mailing Address - Phone:925-225-5837
Mailing Address - Fax:925-225-5838
Practice Address - Street 1:3883 AIRWAY DR STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1678
Practice Address - Country:US
Practice Address - Phone:707-521-4495
Practice Address - Fax:707-573-5421
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77253207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME331190099Medicaid
CAA77253OtherSTATE MEDICAL LICENSE
ME331190099Medicaid