Provider Demographics
NPI:1902898653
Name:RANDOLPH, PAUL D JR (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:RANDOLPH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 S PARKWAY E
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38106-5617
Mailing Address - Country:US
Mailing Address - Phone:901-942-1543
Mailing Address - Fax:901-948-2241
Practice Address - Street 1:661 S PARKWAY E
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-5617
Practice Address - Country:US
Practice Address - Phone:901-346-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD22024207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3373068Medicaid
TN3868333Medicaid
TN3373068Medicare ID - Type UnspecifiedGROUP
TN3373068Medicaid
TN3868333Medicare ID - Type UnspecifiedINDIVIDUAL