Provider Demographics
NPI:1194726380
Name:RANDOLPH, GEOFFREY M (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:M
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 1:7230 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2209
Mailing Address - Country:US
Mailing Address - Phone:260-490-7111
Mailing Address - Fax:260-490-9301
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1715
Practice Address - Country:US
Practice Address - Phone:260-490-7111
Practice Address - Fax:260-490-9301
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035742A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN240007528OtherMEDICARE RAILROAD
MI104366820Medicaid
OH0467338Medicaid
IN100353210Medicaid
OH0467338Medicaid
IN240007528Medicare PIN
IN100353210Medicaid