Provider Demographics
NPI:1205838992
Name:RANDOLPH, DANIEL LEE (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9631 N NEVADA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1134
Mailing Address - Country:US
Mailing Address - Phone:509-625-3760
Mailing Address - Fax:509-625-3789
Practice Address - Street 1:9631 N NEVADA ST STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1134
Practice Address - Country:US
Practice Address - Phone:509-625-3760
Practice Address - Fax:509-625-3789
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1004773Medicaid
WA0200958OtherLABOR & INDUSTRIES
WAF84960Medicare UPIN
WAG886124Medicare PIN