Provider Demographics
NPI:1700801206
Name:RANDELL, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:RANDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5667 PEACHTREE DUNWOODY RD STE 280
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1714
Mailing Address - Country:US
Mailing Address - Phone:404-250-4443
Mailing Address - Fax:404-250-4423
Practice Address - Street 1:5667 PEACHTREE DUNWOODY RD STE 280
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1714
Practice Address - Country:US
Practice Address - Phone:404-250-4443
Practice Address - Fax:404-250-4423
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA40200207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA040200OtherSTATE LIECENCE
GA000676629EMedicaid
16BBCFDMedicare ID - Type Unspecified
GAG15077Medicare UPIN