Provider Demographics
NPI:1750336335
Name:GIBSON, RANDEL (DO)
Entity type:Individual
Prefix:
First Name:RANDEL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DO
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 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-2023
Practice Address - Street 1:353 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863
Practice Address - Country:US
Practice Address - Phone:662-490-1985
Practice Address - Fax:662-490-1989
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02027207Q00000X
MS19706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00279768OtherRR MCR
000000337173OtherBCBS
KY000000047508OtherANTHEM
KY64020274Medicaid
KYD20626Medicare UPIN
000000337173OtherBCBS
KY000000047508OtherANTHEM