MEDICARE: DR. MARK B RANDOLPH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L8483	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L8483	OTHER	TX	STATE LIC NUMBER

General Provider Information

NPI Number	:	1982677209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK B RANDOLPH MD

Provider Business Mailing Address
First Line	:	PO BOX 1621
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78667-1621
Country	:	US
Telephone Number	:	512-878-6330
Fax Number	:	512-878-6941

Provider Business Practice Location Address
First Line	:	1920 CORPORATE DR
Second Line	:	SUITE 208
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-6077
Country	:	US
Telephone Number	:	512-878-6330
Fax Number	:	512-878-6941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	08/17/2012

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