Provider Demographics
NPI:1609803881
Name:RICHARDSON, RANDOLPH MACON IV (DMD MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:MACON
Last Name:RICHARDSON
Suffix:IV
Gender:M
Credentials:DMD MD
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Mailing Address - Street 1:PO BOX 07352
Mailing Address - Street 2:6120 WINKLER RD STE F
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919
Mailing Address - Country:US
Mailing Address - Phone:239-437-1500
Mailing Address - Fax:239-437-1560
Practice Address - Street 1:6120 WINKLER RD
Practice Address - Street 2:STE F
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-437-1500
Practice Address - Fax:239-437-1560
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
FLDN0014165204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F37842Medicare UPIN