Provider Demographics
NPI:1982691549
Name:DECARLO, RANDOLPH A (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:A
Last Name:DECARLO
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 1:701 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5930
Mailing Address - Country:US
Mailing Address - Phone:301-609-4000
Mailing Address - Fax:301-609-4410
Practice Address - Street 1:701 CHARLES ST
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5930
Practice Address - Country:US
Practice Address - Phone:301-609-4000
Practice Address - Fax:301-609-4410
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD44918174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF97128Medicare UPIN