Provider Demographics
NPI:1841637378
Name:LAVENDER, RANDY CHARLES JR (MD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:CHARLES
Last Name:LAVENDER
Suffix:JR
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 1:902 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3270
Mailing Address - Country:US
Mailing Address - Phone:229-276-3100
Mailing Address - Fax:
Practice Address - Street 1:910 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3254
Practice Address - Country:US
Practice Address - Phone:229-276-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140940207X00000X
GA93479207X00000X, 207XS0114X
LA328483207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL754378Medicaid