Organization
THEODORE RANDOLPH,DPM
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THEODORE JOHN RANDOLPH DPM (OWNER)
(631) 928-7785
Entity
Organization
Contact information
Practice address
3 MEDICAL DR, SUITE C, PORT JEFFERSON STATION, NY 11776-1597
(631) 928-7785
(631) 928-0316
Mailing address
3 MEDICAL DR, SUITE C, PORT JEFFERSON STATION, NY 11776-1597
(631) 928-7785
(631) 928-0316
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
003646
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
791048
—
NY
Enumeration date
01/15/2008
Last updated
01/16/2008
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