Provider Demographics
NPI:1942320106
Name:KNIGHT, RANDOLPH R (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:R
Last Name:KNIGHT
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:PO BOX 1110
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02471-1110
Mailing Address - Country:US
Mailing Address - Phone:866-679-0831
Mailing Address - Fax:802-332-3117
Practice Address - Street 1:5 S MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7146
Practice Address - Country:US
Practice Address - Phone:866-679-0831
Practice Address - Fax:802-332-3117
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0014564207Q00000X
FLME143693207Q00000X
NH10087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTORE4593Medicaid
VTORE4593Medicaid
NHRE4593Medicare ID - Type UnspecifiedMEDICARE