Provider Demographics
NPI:1740249192
Name:RANDOLPH, TODD LENWELL (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:LENWELL
Last Name:RANDOLPH
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 1:5100 TALLEY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-8040
Mailing Address - Country:US
Mailing Address - Phone:501-500-6640
Mailing Address - Fax:
Practice Address - Street 1:5100 TALLEY RD STE 300
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8040
Practice Address - Country:US
Practice Address - Phone:501-500-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT318197-1205207ZP0102X, 207ZC0500X
IN01082681A207ZP0102X, 207ZC0500X
ARE15550207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870326048001D1686Medicaid
IN068010881OtherMEDICARE