Provider Demographics
NPI:1932174877
Name:RANDOLPH, SANDRA BOYLAND (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:BOYLAND
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7424 US HIGHWAY 64
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-3986
Mailing Address - Country:US
Mailing Address - Phone:901-385-7817
Mailing Address - Fax:901-383-2150
Practice Address - Street 1:7424 US HIGHWAY 64
Practice Address - Street 2:SUITE 111
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-3986
Practice Address - Country:US
Practice Address - Phone:901-385-7817
Practice Address - Fax:901-383-2150
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN26259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG31865Medicare UPIN