Provider Demographics
NPI:1346209756
Name:RANDOLPH, MICHELLE L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 DEBARR ROAD SUITE 402
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-531-5213
Mailing Address - Fax:907-531-5013
Practice Address - Street 1:2741 DEBARR ROAD SUITE 402
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-531-5213
Practice Address - Fax:907-531-5013
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7641207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1583849Medicaid