Provider Demographics
NPI:1922022235
Name:RANDOLPH, SHERON M (MD)
Entity Type:Individual
Prefix:
First Name:SHERON
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:317-621-7584
Mailing Address - Fax:317-957-2705
Practice Address - Street 1:1011 MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-6978
Practice Address - Country:US
Practice Address - Phone:317-957-9150
Practice Address - Fax:317-957-9965
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047330A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200328390Medicaid
INP01424263OtherRAIL ROAD PTAN
IN000000744272OtherBCBS
IN266180415Medicare PIN
INM400035625Medicare PIN