Provider Demographics
NPI:1093793424
Name:POPP, RANDI KATHERINE (MD)
Entity Type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:KATHERINE
Last Name:POPP
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 1:106 RIVERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-6033
Mailing Address - Country:US
Mailing Address - Phone:843-870-8489
Mailing Address - Fax:
Practice Address - Street 1:1483 TOBIAS GADSON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-8702
Practice Address - Country:US
Practice Address - Phone:843-766-6229
Practice Address - Fax:843-766-2315
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD19704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC197049Medicaid
SC8231Medicare PIN
SC197049Medicaid