Basic Information
| Provider Information | |||||||||
| NPI: | 1497250096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | A-2474-21 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.