Provider Demographics
NPI:1326615717
Name:RANDOLPH, BRIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2784 MARSHALL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-1148
Mailing Address - Country:US
Mailing Address - Phone:703-606-7161
Mailing Address - Fax:
Practice Address - Street 1:3930 PENDER DR STE 10
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0986
Practice Address - Country:US
Practice Address - Phone:703-273-2398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist