Provider Demographics
NPI:1801851522
Name:WHITE, RANDALL G (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:G
Last Name:WHITE
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 1:745 OLIVE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2246
Mailing Address - Country:US
Mailing Address - Phone:318-226-0809
Mailing Address - Fax:318-226-0812
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-226-0809
Practice Address - Fax:318-226-0812
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020186207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL020186OtherMEDICAL LICENSE
LA1966118Medicaid
LA1966118Medicaid
LAL020186OtherMEDICAL LICENSE
LAF53662Medicare UPIN