Basic Information
| Provider Information | |||||||||
| NPI: | 1801851522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 OLIVE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182260809 | ||||||||
| FaxNumber: | 3182260812 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 OLIVE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182260809 | ||||||||
| FaxNumber: | 3182260812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 020186 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | L020186 | 01 | LA | MEDICAL LICENSE | OTHER | 1966118 | 05 | LA | MEDICAID |