Healthcare Provider Details

I. General information

NPI: 1194200121
Provider Name (Legal Business Name): AMBER TIFFANY RANDOLPH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 S WOOD ST
CHICAGO IL
60612-3747
US

IV. Provider business mailing address

1009 S WOOD ST
CHICAGO IL
60612-3747
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036.178700
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: