Provider Demographics
NPI:1790806503
Name:RANDOLPH, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11177 W 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-5575
Mailing Address - Country:US
Mailing Address - Phone:303-233-3363
Mailing Address - Fax:303-233-4622
Practice Address - Street 1:9808 W CEDAR AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-1023
Practice Address - Country:US
Practice Address - Phone:303-233-3363
Practice Address - Fax:303-233-4622
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO345302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG17018Medicare UPIN
COG7149Medicare PIN