Healthcare Provider Details

I. General information

NPI: 1326079799
Provider Name (Legal Business Name): RANDOLPH LEIGH COPELAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD. BOX 1337
GALLUP NM
87301-1337
US

IV. Provider business mailing address

516 E. NIZHONI BLVD. BOX 1337
GALLUP NM
87301-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1256
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number025131
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD.013119
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: