Provider Demographics
NPI:1477553550
Name:FOX, RANDALL MARK (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:MARK
Last Name:FOX
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 1:2650 LAKE SHORE DR UNIT 1404
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-4611
Mailing Address - Country:US
Mailing Address - Phone:561-612-0974
Mailing Address - Fax:
Practice Address - Street 1:1901 S CONGRESS AVE STE 420
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6588
Practice Address - Country:US
Practice Address - Phone:561-364-1479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110363207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3099629Medicare ID - Type Unspecified
D51016Medicare UPIN