MEDICARE: DR. TOMMY LAVAUGHN RANDOLPH M.D.

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	ME46235	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080154675	OTHER	FL	RRMEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12070	OTHER	FL	BCBS
3	030335	OTHER	FL	AVMED
4	1992805881	OTHER	FL	NPI
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	0004055514	OTHER	FL	AETNA

General Provider Information

NPI Number	:	1992805881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TOMMY LAVAUGHN RANDOLPH M.D.

Provider Business Mailing Address
First Line	:	1847 SW BARNETT WAY
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6957
Country	:	US
Telephone Number	:	386-755-1440
Fax Number	:	386-758-5628

Provider Business Practice Location Address
First Line	:	1847 SW BARNETT WAY
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6957
Country	:	US
Telephone Number	:	386-755-1440
Fax Number	:	386-758-5628

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	01/03/2014

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Directions to “ DR. TOMMY LAVAUGHN RANDOLPH M.D.” Practice Location

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