Provider Demographics
NPI:1861484594
Name:RANDOLPH, DONNA W (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:W
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 POPLAR AVE
Mailing Address - Street 2:DEPT 299
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6426
Mailing Address - Country:US
Mailing Address - Phone:901-274-3550
Mailing Address - Fax:901-274-3551
Practice Address - Street 1:1726 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6426
Practice Address - Country:US
Practice Address - Phone:901-274-3550
Practice Address - Fax:901-274-3551
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD24938207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3373068Medicaid
TN3093788Medicaid
TN3099789Medicaid
TN103I165972OtherMEDICARE PTAN
TN103I165972OtherMEDICARE PTAN