Provider Demographics
NPI:1528173697
Name:RANDOLPH, GANNON B (MD)
Entity type:Individual
Prefix:
First Name:GANNON
Middle Name:B
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3317 N WIMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4056
Mailing Address - Country:US
Mailing Address - Phone:479-521-2752
Mailing Address - Fax:479-521-4603
Practice Address - Street 1:1800 SE MOBERLY LN
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-7017
Practice Address - Country:US
Practice Address - Phone:479-521-2752
Practice Address - Fax:479-521-4603
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5957207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1176259001Medicaid
AR5H5147318Medicare PIN
P00340349Medicare PIN
ID807568800Medicaid
AR5H5147318OtherBLUE CROSS BLUE SHEILD
AR176259001Medicaid
1134072Medicare PIN
I37950Medicare UPIN