Basic Information
| Provider Information | |||||||||
| NPI: | 1104026756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIZARDO | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8110 MAPLE LAWN BLVD STE 235 | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013408339 | ||||||||
| FaxNumber: | 3013409027 | ||||||||
| Practice Location | |||||||||
| Address1: | 10313 GEORGIA AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209025006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016819101 | ||||||||
| FaxNumber: | 3016813525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | D0066274 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 413225400 | 05 | MD | MEDICAID |