Provider Demographics
NPI:1689677882
Name:RANDOLPH, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:RANDOLPH
Suffix:
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:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-0919
Mailing Address - Country:US
Mailing Address - Phone:864-897-8277
Mailing Address - Fax:864-878-0035
Practice Address - Street 1:105 LIBERTY BLVD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1641
Practice Address - Country:US
Practice Address - Phone:864-843-8500
Practice Address - Fax:864-843-5634
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074072207Q00000X
SC24613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2141300Medicaid
OH2141300Medicaid
OHG94103Medicare UPIN