Provider Demographics
NPI:1053672675
Name:GIBBS, RANDOLPH DOUGLAS II (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:DOUGLAS
Last Name:GIBBS
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 UNIVERSITY DR E STE 455
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3478
Mailing Address - Country:US
Mailing Address - Phone:979-704-5029
Mailing Address - Fax:979-704-5033
Practice Address - Street 1:3201 UNIVERSITY DR E STE 320
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3478
Practice Address - Country:US
Practice Address - Phone:979-704-5029
Practice Address - Fax:979-704-5033
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR51192086S0105X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18286Medicaid
ND18286Medicaid
NDN719226Medicare PIN