Provider Demographics
NPI:1982775706
Name:RANDOLPH, ANDREW JEROME (MD, PA)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JEROME
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1025 NORTH STONE STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:386-734-1130
Practice Address - Street 1:1025 N STONE ST
Practice Address - Street 2:SUITE B
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0803
Practice Address - Country:US
Practice Address - Phone:386-734-4453
Practice Address - Fax:386-734-1130
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL49576207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10718618OtherCAQH PROVIDER #
FL044348400Medicaid
FL592870603OtherTAX ID
FL02590OtherPROVIDER #
FL044348400Medicaid