Individual
DR. ANDREW JEROME RANDOLPH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D., P.A.
Contact information
Practice address
1025 N STONE ST, SUITE B, DELAND, FL 32720-0803
(386) 734-4453
(386) 734-1130
Mailing address
1025 NORTH STONE STREET, SUITE B, DELAND, FL 32720
(386) 734-1130
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
49576
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
02590
PROVIDER #
FL
05
—
044348400
—
FL
01
—
10718618
CAQH PROVIDER #
FL
01
—
592870603
TAX ID
FL
Enumeration date
11/13/2006
Last updated
07/09/2010
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