Provider Demographics
NPI:1760040281
Name:RANDOLPH, CHARLES D (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
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 1:411 FORTUYN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND COULEE
Mailing Address - State:WA
Mailing Address - Zip Code:99133-8718
Mailing Address - Country:US
Mailing Address - Phone:509-633-1911
Mailing Address - Fax:509-633-3644
Practice Address - Street 1:411 FORTUYN RD
Practice Address - Street 2:
Practice Address - City:GRAND COULEE
Practice Address - State:WA
Practice Address - Zip Code:99133-8718
Practice Address - Country:US
Practice Address - Phone:509-633-1911
Practice Address - Fax:509-633-3644
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61172546207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2136043Medicaid