Provider Demographics
NPI:1992805881
Name:RANDOLPH, TOMMY LAVAUGHN (MD)
Entity type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:LAVAUGHN
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1847 SW BARNETT WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6957
Mailing Address - Country:US
Mailing Address - Phone:386-755-1440
Mailing Address - Fax:386-758-5628
Practice Address - Street 1:1847 SW BARNETT WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6957
Practice Address - Country:US
Practice Address - Phone:386-755-1440
Practice Address - Fax:386-758-5628
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12070OtherBCBS
FL080154675OtherRRMEDICARE
FL030335OtherAVMED
FL1992805881OtherNPI
FL041374700Medicaid
FL0004055514OtherAETNA
FL0004055514OtherAETNA
FL080154675OtherRRMEDICARE