Provider Demographics
NPI:1811511033
Name:RANDOLPH, MILDRED B (DO)
Entity type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:B
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:405 HURFFVILLE CROSSKEYS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-9340
Mailing Address - Country:US
Mailing Address - Phone:856-218-0300
Mailing Address - Fax:856-589-5082
Practice Address - Street 1:405 HURFFVILLE CROSSKEYS RD STE 101
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-9340
Practice Address - Country:US
Practice Address - Phone:856-218-0300
Practice Address - Fax:856-589-5082
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB11608200207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine