Provider Demographics
NPI:1023663317
Name:RANDOLPH, ZACHARY JAMES (DPT)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:JAMES
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60368 COTTON GIN PORT RD
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821
Mailing Address - Country:US
Mailing Address - Phone:662-257-3669
Mailing Address - Fax:662-257-3961
Practice Address - Street 1:60368 COTTON GIN PORT RD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821
Practice Address - Country:US
Practice Address - Phone:662-257-3669
Practice Address - Fax:662-257-3961
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist