Provider Demographics
NPI:1750352647
Name:THORNTON, RANDOLPH E (M D)
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:E
Last Name:THORNTON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4520
Mailing Address - Country:US
Mailing Address - Phone:904-388-4646
Mailing Address - Fax:904-388-9017
Practice Address - Street 1:2606 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4520
Practice Address - Country:US
Practice Address - Phone:904-388-4646
Practice Address - Fax:904-388-9017
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048083208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0645079-01Medicaid
FLD52497Medicare UPIN