Provider Demographics
NPI:1417930843
Name:HEAD, RANDY W (MD APMC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:W
Last Name:HEAD
Suffix:
Gender:M
Credentials:MD APMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 COLLINS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-3388
Mailing Address - Country:US
Mailing Address - Phone:318-649-5300
Mailing Address - Fax:318-649-0052
Practice Address - Street 1:484 COLLINS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-3388
Practice Address - Country:US
Practice Address - Phone:318-649-5300
Practice Address - Fax:318-649-0052
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1663280Medicaid
LA1663280Medicaid
LA488978YJYXMedicare PIN