Provider Demographics
NPI:1447487301
Name:RANDOLPH, JESSICA DIONNE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DIONNE
Last Name:RANDOLPH
Suffix:
Gender:F
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 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:401 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1901
Practice Address - Country:US
Practice Address - Phone:804-828-8643
Practice Address - Fax:804-828-1010
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101254363207W00000X
NC2015-00754207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX291170YSLAMedicare PIN
TX322600301Medicaid
TX291170YSLAMedicare PIN