Basic Information
| Provider Information | |||||||||
| NPI: | 1124078118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLVIN | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1967 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308091967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069228251 | ||||||||
| FaxNumber: | 7069226695 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 MAGNOLIA WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069226600 | ||||||||
| FaxNumber: | 7066500239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 060165 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | T26638 | 05 | SC | MEDICAID |