Provider Demographics
NPI:1164621330
Name:RANDOLPH, JOHN CARLTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CARLTON
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 AVENUE K SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3914
Mailing Address - Country:US
Mailing Address - Phone:863-297-5400
Mailing Address - Fax:866-914-5210
Practice Address - Street 1:250 AVENUE K SW
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3914
Practice Address - Country:US
Practice Address - Phone:863-297-5400
Practice Address - Fax:863-595-4515
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253705207W00000X
TN47205207W00000X
FLME119936207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHV644ZMedicare PIN
TN103I188300Medicare PIN