Provider Demographics
NPI:1104026756
Name:LIZARDO, RANDOLPH DEAN (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:DEAN
Last Name:LIZARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:301-340-9027
Practice Address - Street 1:10313 GEORGIA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5006
Practice Address - Country:US
Practice Address - Phone:301-681-9101
Practice Address - Fax:301-681-3525
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066274207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413225400Medicaid
MDG00121Medicare UPIN
MD022768C21Medicare PIN