Provider Demographics
NPI:1942389978
Name:RANDOLPH, GARY D (DP)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:GUIN
Mailing Address - State:AL
Mailing Address - Zip Code:35563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7596 US HWY 43
Practice Address - Street 2:
Practice Address - City:GUIN
Practice Address - State:AL
Practice Address - Zip Code:35563
Practice Address - Country:US
Practice Address - Phone:205-468-3464
Practice Address - Fax:205-468-3724
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0137111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T68550Medicare UPIN
AL0007003800000Medicare ID - Type Unspecified