Provider Demographics
NPI:1437704756
Name:RANDOLPH, BYRON MARTIN (DPT)
Entity type:Individual
Prefix:DR
First Name:BYRON
Middle Name:MARTIN
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 EASTGATE DR APT 2204
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-2862
Mailing Address - Country:US
Mailing Address - Phone:813-523-3502
Mailing Address - Fax:
Practice Address - Street 1:7932 SAND LAKE RD STE 203
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819
Practice Address - Country:US
Practice Address - Phone:407-355-9820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34719225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist