Provider Demographics
NPI:1033106422
Name:HUNTER, RANDOLPH GRAY (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:GRAY
Last Name:HUNTER
Suffix:
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 1:1934 SALK AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0000
Mailing Address - Country:US
Mailing Address - Phone:352-742-2201
Mailing Address - Fax:
Practice Address - Street 1:1934 SALK AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-0000
Practice Address - Country:US
Practice Address - Phone:352-742-2201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0075959208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2553716-00Medicaid
FL2553716-00Medicaid
FLC74470Medicare UPIN