Individual
GEOFFREY M RANDOLPH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
11141 PARKVIEW PLAZA DR STE 300, FORT WAYNE, IN 46845-1715
(260) 490-7111
(260) 490-9301
Mailing address
7230 ENGLE RD, FORT WAYNE, IN 46804-2209
(260) 490-7111
(260) 490-9301
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
01035742A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0467338
—
OH
05
—
100353210
—
IN
05
—
104366820
—
MI
01
—
240007528
MEDICARE RAILROAD
IN
Enumeration date
08/10/2005
Last updated
07/23/2018
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