Provider Demographics
NPI:1700944279
Name:MAXEY, RANDALL WHITAKER (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WHITAKER
Last Name:MAXEY
Suffix:
Gender:M
Credentials:MD PHD
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 83246
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90083-0246
Mailing Address - Country:US
Mailing Address - Phone:310-680-1810
Mailing Address - Fax:310-680-1811
Practice Address - Street 1:447 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1413
Practice Address - Country:US
Practice Address - Phone:310-680-1810
Practice Address - Fax:310-680-1811
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38014207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C380140Medicaid
CA00C380140Medicaid
CAWC38014JMedicare PIN