Provider Demographics
NPI:1750389482
Name:RANDOLPH, JOHN FRANKLIN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FRANKLIN
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:PO BOX 7779
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-0779
Mailing Address - Country:US
Mailing Address - Phone:951-205-0937
Mailing Address - Fax:909-580-1916
Practice Address - Street 1:410 E PARKCENTER CIR N
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2869
Practice Address - Country:US
Practice Address - Phone:909-501-9932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48108207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065470Medicaid
CAA50936Medicare UPIN
CAA50936Medicare UPIN