Randolph, Theodore John

Randolph, Theodore John is an sole proprietor health care provider with primary practice located at 3 Medical Dr Suite C, Port Jefferson Station NY 11776-1597. He recently has only one registered license in Podiatric Medicine & Surgery Service Providers / Foot & Ankle Surgery, which is considered as his primary health care specialty. Randolph, Theodore John can be contacted via phone (631) 928-7785.

Contact Information

Primary practice address
3 Medical Dr Suite C Port Jefferson Station NY 11776-1597
Phone: (631) 928-7785
Fax: (631) 928-0316
Website:
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Health care specialties

SpecialtyCodeLicense #State
Podiatric Medicine & Surgery Service Providers / Foot & Ankle Surgery 213ES0103X 003646 New York

Profile Details

NPI number 1831197318
LBN Legal business name Randolph, Theodore John
Credentials Doctor of Podiatric Medicine (DPM)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Jul 8th, 2005
Last updated Oct 20th, 2011 - about 13 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1831197318 NPPES
New York MEDICAID 791048

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