Provider Demographics
NPI:1699760652
Name:RANDOLPH, GREGORY W (MD)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:W
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FLEITAS AVE
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-4507
Mailing Address - Country:US
Mailing Address - Phone:228-452-4888
Mailing Address - Fax:228-452-5006
Practice Address - Street 1:130 FLEITAS AVE
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-4507
Practice Address - Country:US
Practice Address - Phone:228-452-4888
Practice Address - Fax:228-452-5006
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13081208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117253Medicaid
MSG18746Medicare UPIN