Provider Demographics
NPI:1407125594
Name:JORDAN-RANDOLPH, GAYLE (MD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:JORDAN-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 1:920 SAINT PAUL ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2423
Mailing Address - Country:US
Mailing Address - Phone:410-727-4663
Mailing Address - Fax:
Practice Address - Street 1:920 SAINT PAUL ST APT 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-6512
Practice Address - Country:US
Practice Address - Phone:410-727-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD440782084F0202X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry