Healthcare Provider Details

I. General information

NPI: 1295199016
Provider Name (Legal Business Name): RANDALL GLEN WHITE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HOSPITAL DR STE 120
BOSSIER CITY LA
71111
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-7982
  • Fax: 318-212-7989
Mailing address:
  • Phone: 318-212-8951
  • Fax: 318-212-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number313083
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: