Provider Demographics
NPI:1497726814
Name:MALONE, RANDOLPH AUGUSTUS IV (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:AUGUSTUS
Last Name:MALONE
Suffix:IV
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 1:2804 REMINGTON GREEN CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:229-226-5616
Mailing Address - Fax:229-226-7132
Practice Address - Street 1:2804 REMINGTON GREEN CIRCLE STE1
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-656-6269
Practice Address - Fax:850-877-5270
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
060041174400000X
GA034412207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000465671AMedicaid
GAE62149Medicare UPIN
FL12395Medicare PIN
GA03BDBCRMedicare PIN
GA03BDBCRMedicare PIN