Provider Demographics
NPI:1245286780
Name:ROYAL RANDOLPH, JR., M.D., M.P.H., LLC
Entity type:Organization
Organization Name:ROYAL RANDOLPH, JR., M.D., M.P.H., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROYAL
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:808-244-9677
Mailing Address - Street 1:PO BOX 1441
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-6441
Mailing Address - Country:US
Mailing Address - Phone:808-244-9677
Mailing Address - Fax:808-242-4805
Practice Address - Street 1:2200 MAIN ST
Practice Address - Street 2:SUITE 517
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1681
Practice Address - Country:US
Practice Address - Phone:808-244-9677
Practice Address - Fax:808-244-9677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-49462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI017302-01Medicaid
HI192779OtherHMA, INC HAWAII
HI192779OtherHAWAII ELECTRICIANS HEALT
HI1853-1OtherHMSA
HI192779OtherSUMMERLIN LIFE & HEALTH
HIA-48199OtherKAISER AFFILIATED CARE
HI=========OtherHMAA
HI192779OtherHAWAII ELECTRICIANS HEALT