Provider Demographics
NPI:1497808182
Name:CLEVELAND W. RANDOLPH JR MD,PA
Entity Type:Organization
Organization Name:CLEVELAND W. RANDOLPH JR MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEVELAND
Authorized Official - Middle Name:W
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-249-3743
Mailing Address - Street 1:1891 BEACH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2644
Mailing Address - Country:US
Mailing Address - Phone:904-249-3743
Mailing Address - Fax:904-249-2047
Practice Address - Street 1:1891 BEACH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2644
Practice Address - Country:US
Practice Address - Phone:904-249-3743
Practice Address - Fax:904-249-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK-5271Medicare PIN