Provider Demographics
NPI:1497769665
Name:RANDLE, GERALD (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:RANDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-292-4261
Mailing Address - Fax:601-292-4262
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:SUITE 420
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2000
Practice Address - Country:US
Practice Address - Phone:601-355-3353
Practice Address - Fax:601-355-3365
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS062332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00466199OtherRR MEDICARE
MS300002201OtherUS DEPT OF LABOR
MS753068151OtherMPCN
MS00124228Medicaid
MS753068151OtherMHP
753068151014OtherTRICARE
MS00124228Medicaid