Provider Demographics
NPI:1760820831
Name:RANDOLPH, TIENNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIENNE
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIENNE
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8051 S EMERSON AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8633
Mailing Address - Country:US
Mailing Address - Phone:317-865-3600
Mailing Address - Fax:317-885-3850
Practice Address - Street 1:8051 S EMERSON AVE STE 400
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8633
Practice Address - Country:US
Practice Address - Phone:317-865-3600
Practice Address - Fax:317-885-3850
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078766A207V00000X
IN11017248A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017269Medicaid
IN01078766AOtherLICENSE