Healthcare Provider Details

I. General information

NPI: 1649276007
Provider Name (Legal Business Name): BRYAN WAYNE RANDOLPH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 E BERT KOUN LOOP STE 101
SHREVEPORT LA
71105-5663
US

IV. Provider business mailing address

7821 YOUREE DR
SHREVEPORT LA
71105-5505
US

V. Phone/Fax

Practice location:
  • Phone: 318-681-4282
  • Fax:
Mailing address:
  • Phone: 318-213-3668
  • Fax: 318-213-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPD290R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM.PD290R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: