Healthcare Provider Details

I. General information

NPI: 1750389482
Provider Name (Legal Business Name): JOHN FRANKLIN RANDOLPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E PARKCENTER CIR N
SAN BERNARDINO CA
92408-2869
US

IV. Provider business mailing address

PO BOX 7779
REDLANDS CA
92375-0779
US

V. Phone/Fax

Practice location:
  • Phone: 909-501-9932
  • Fax:
Mailing address:
  • Phone: 951-205-0937
  • Fax: 909-580-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberG48108
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: