Provider Demographics
NPI:1417043365
Name:RANDALL, GAYLE MADELEINE (MD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:MADELEINE
Last Name:RANDALL
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 1:23123 VENTURA BLVD
Mailing Address - Street 2:SUITE 104A
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1104
Mailing Address - Country:US
Mailing Address - Phone:818-591-7600
Mailing Address - Fax:818-591-7605
Practice Address - Street 1:23123 VENTURA BLVD
Practice Address - Street 2:SUITE 104A
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1162
Practice Address - Country:US
Practice Address - Phone:818-591-7600
Practice Address - Fax:818-591-7600
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93121Medicare UPIN