Provider Demographics
NPI:1497761365
Name:WHITE-RANDALL, ELIZABETH C (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:WHITE-RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:C
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:76 HIGH ST
Mailing Address - Street 2:PO BOX 819
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7649
Mailing Address - Country:US
Mailing Address - Phone:207-795-2800
Mailing Address - Fax:207-795-2808
Practice Address - Street 1:76 HIGH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7649
Practice Address - Country:US
Practice Address - Phone:207-795-2800
Practice Address - Fax:207-795-2808
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012395207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME213170099Medicaid
MEC66311Medicare UPIN
MEMM1075Medicare PIN