Basic Information
| Provider Information | |||||||||
| NPI: | 1982677209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1621 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786671621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128786330 | ||||||||
| FaxNumber: | 5128786941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1920 CORPORATE DR | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786666077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128786330 | ||||||||
| FaxNumber: | 5128786941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L8483 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | L8483 | 01 | TX | STATE LIC NUMBER | OTHER |