Provider Demographics
NPI:1548245400
Name:RANDOLPH, ALBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALBERT
Other - Middle Name:M
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1398
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0309
Mailing Address - Country:US
Mailing Address - Phone:509-527-8151
Mailing Address - Fax:509-527-8010
Practice Address - Street 1:1111 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4118
Practice Address - Country:US
Practice Address - Phone:509-527-8151
Practice Address - Fax:509-527-8010
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030135207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1012960Medicaid
WAG8894230Medicare PIN