Provider Demographics
NPI:1326079799
Name:COPELAND, RANDOLPH LEIGH (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:LEIGH
Last Name:COPELAND
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 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1256
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1256
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025131207XP3100X
LAMD.013119207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000E5728Medicaid
AZ580218Medicaid
TX8HZ055Medicare ID - Type UnspecifiedHSZ005
TX8HZ133Medicare ID - Type UnspecifiedHSZ001
NM000E5728Medicaid
AZ580218Medicaid
TX8HZ025Medicare ID - Type UnspecifiedHSZ002
H37695Medicare UPIN