Basic Information
| Provider Information | |||||||||
| NPI: | 1750352647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THORNTON | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2606 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884646 | ||||||||
| FaxNumber: | 9043889017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2606 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884646 | ||||||||
| FaxNumber: | 9043889017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME0048083 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0645079-01 | 05 | FL | MEDICAID |