Basic Information
| Provider Information | |||||||||
| NPI: | 1750459459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | DALLIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | RANDOLPH | ||||||||
| OtherFirstName: | DALLIN | ||||||||
| OtherMiddleName: | TERESA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 224 BARRY STREET | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30030 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1405 CLIFTON RD NE | ||||||||
| Address2: | DIVISION OF EMERGENCY MEDICINE | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857142 | ||||||||
| FaxNumber: | 4047857989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 032279 | GA | X | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | 032279 | GA | X | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.