Provider Demographics
NPI:1649248196
Name:CLEVELAND, RANDOLPH (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:CLEVELAND
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 863481
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3481
Mailing Address - Country:US
Mailing Address - Phone:800-514-1494
Mailing Address - Fax:
Practice Address - Street 1:2815 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7934
Practice Address - Country:US
Practice Address - Phone:561-737-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067253207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32285OtherBCBS
FLP00217018OtherRR MCR
FL32285BMedicare PIN
FLP00217018OtherRR MCR
FLG63187Medicare UPIN