Provider Demographics
NPI:1649276007
Name:RANDOLPH, BRYAN WAYNE (DPM)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:WAYNE
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7821 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5505
Mailing Address - Country:US
Mailing Address - Phone:318-213-3668
Mailing Address - Fax:318-213-3670
Practice Address - Street 1:7821 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5505
Practice Address - Country:US
Practice Address - Phone:318-213-3668
Practice Address - Fax:318-213-3670
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD290R213E00000X
LADPM.PD290R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1436127Medicaid
LA4B661Medicare ID - Type Unspecified
LA1436127Medicaid