Healthcare Provider Details

I. General information

NPI: 1487859294
Provider Name (Legal Business Name): RANDOLPH DOUGLAS GIBBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91275 66TH AVE SUITE 500
MECCA CA
92254
US

IV. Provider business mailing address

91275 66TH AVE SUITE 500
MECCA CA
92254
US

V. Phone/Fax

Practice location:
  • Phone: 614-659-0871
  • Fax:
Mailing address:
  • Phone: 760-396-1249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number35046271
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: