Provider Demographics
NPI:1831197318
Name:RANDOLPH, THEODORE JOHN (DPM)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MEDICAL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1597
Mailing Address - Country:US
Mailing Address - Phone:631-928-7785
Mailing Address - Fax:631-928-0316
Practice Address - Street 1:3 MEDICAL DR
Practice Address - Street 2:SUITE C
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1597
Practice Address - Country:US
Practice Address - Phone:631-928-7785
Practice Address - Fax:631-928-0316
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003646213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY791048Medicaid
NYP92181Medicare ID - Type Unspecified
NY791048Medicaid