Provider Demographics
NPI:1497736870
Name:BLACK, RANDOLPH E (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:E
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7110 WYOMING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4867
Mailing Address - Country:US
Mailing Address - Phone:505-346-0500
Mailing Address - Fax:505-346-0164
Practice Address - Street 1:7110 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4867
Practice Address - Country:US
Practice Address - Phone:505-346-0500
Practice Address - Fax:505-346-0164
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM83165207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33357Medicaid
NM33357Medicaid