Provider Demographics
NPI:1134435704
Name:RANDOLPH, JOSEPH LEE (MPT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEE
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:3000 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-8616
Practice Address - Country:US
Practice Address - Phone:941-406-9023
Practice Address - Fax:904-208-5077
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004020026282N00000X
FLPT34515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No282N00000XHospitalsGeneral Acute Care Hospital