Provider Demographics
NPI:1891859476
Name:MARK RANDOLPH MD PA
Entity Type:Organization
Organization Name:MARK RANDOLPH MD PA
Other - Org Name:RANDOLPH FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-878-6330
Mailing Address - Street 1:PO BOX 1621
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78667-1621
Mailing Address - Country:US
Mailing Address - Phone:512-878-6330
Mailing Address - Fax:512-878-6941
Practice Address - Street 1:1920 CORPORATE DR
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6077
Practice Address - Country:US
Practice Address - Phone:512-878-6330
Practice Address - Fax:512-878-6941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8483261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI52835Medicare UPIN