Provider Demographics
NPI:1295711141
Name:EDWARDS, RANDOLPH ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:ANTHONY
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 340581
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-0581
Mailing Address - Country:US
Mailing Address - Phone:507-279-2052
Mailing Address - Fax:
Practice Address - Street 1:1332 E 104TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4508
Practice Address - Country:US
Practice Address - Phone:507-279-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32957208600000X
WAMD60178868208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery