Provider Demographics
NPI:1982677209
Name:RANDOLPH, MARK B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
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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
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2012-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL8483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL8483OtherSTATE LIC NUMBER