Provider Demographics
NPI:1447216866
Name:RANDOLPH, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-213-5770
Mailing Address - Fax:757-627-0334
Practice Address - Street 1:5900 LAKE WRIGHT DR STE B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-1871
Practice Address - Country:US
Practice Address - Phone:757-213-5770
Practice Address - Fax:757-627-0334
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101 0369622085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPAROtherUSA MANAGED CARE
VA10035953OtherSENTARA/OPTIMA
NC10259OtherBC/BS
VAPAROtherAETNA
NC5910259Medicaid
VA6181967OtherUHC/MAMSI
VAPAROtherCORVEL/CORCARE
VAPAROtherVA HEALTH NETWORK
VAPAROtherTRICARE/CHAMPUS
VAPAROtherMULTIPLAN
VA1447216866Medicaid
VA359100OtherANTHEM
VAPAROtherVIRGINIA PREMIER HEALTH
VA9841062OtherCIGNA
VAPAROtherFIRST HEALTH COMMERICAL
NC10259OtherBC/BS
VAPAROtherCORVEL/CORCARE
NC5910259Medicaid