Basic Information
| Provider Information | |||||||||
| NPI: | 1487859294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91275 66TH AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MECCA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603961249 | ||||||||
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| Practice Location | |||||||||
| Address1: | 91275 66TH AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MECCA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146590871 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 01/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202C00000X | 35046271 | OH | Y | Allopathic & Osteopathic Physicians | Independent Medical Examiner |
ID Information
| ID | Type | State | Issuer | Description | 0504029 | 05 | OH | MEDICAID |