Provider Demographics
NPI:1831470426
Name:RANDALL, MARK LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:RANDALL
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 1:200 CARRAWAY DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35594-5048
Mailing Address - Country:US
Mailing Address - Phone:205-487-7661
Mailing Address - Fax:
Practice Address - Street 1:200 CARRAWAY DR
Practice Address - Street 2:SUITE 2
Practice Address - City:WINFIELD
Practice Address - State:AL
Practice Address - Zip Code:35594-5048
Practice Address - Country:US
Practice Address - Phone:205-487-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.18944208600000X
AL18944208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51511859Medicare PIN
ALG02887Medicare UPIN