Individual
THEODORE JOHN RANDOLPH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.P.M
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
07/08/2005
Last updated
10/20/2011
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