Provider Demographics
NPI:1275632325
Name:RANDOLPH, RICHARD C (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:348 CROSSGATES BLVD
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2616
Mailing Address - Country:US
Mailing Address - Phone:601-825-2466
Mailing Address - Fax:601-824-8137
Practice Address - Street 1:348 CROSSGATES BLVD
Practice Address - Street 2:SUITE 2200
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2616
Practice Address - Country:US
Practice Address - Phone:601-825-2466
Practice Address - Fax:601-824-8137
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS10006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116695Medicaid
MS080190935OtherPALMETTO GBA RAILROAD MEDICARE
MS080190935OtherPALMETTO GBA RAILROAD MEDICARE
MSAR2130944OtherDEA
MS00116695Medicaid