Provider Demographics
NPI:1487859294
Name:GIBBS, RANDOLPH DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:DOUGLAS
Last Name:GIBBS
Suffix:
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 1:91275 66TH AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MECCA
Mailing Address - State:CA
Mailing Address - Zip Code:92254
Mailing Address - Country:US
Mailing Address - Phone:760-396-1249
Mailing Address - Fax:
Practice Address - Street 1:91275 66TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:MECCA
Practice Address - State:CA
Practice Address - Zip Code:92254
Practice Address - Country:US
Practice Address - Phone:614-659-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046271202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0504029Medicaid
OH0504029Medicaid
OHCO2303Medicare UPIN