Randolph, Gannon B

Randolph, Gannon B is an individual health care provider with primary practice located at 1800 Se Moberly Ln , Bentonville AR 72712-7017. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Orthopaedic Surgery, Allopathic & Osteopathic Physicians / Orthopaedic Surgery of the Spine. Allopathic & Osteopathic Physicians / Orthopaedic Surgery of the Spine is his primary health care specialty. Randolph, Gannon B can be contacted via phone (479) 521-2752.

Contact Information

Primary practice address
1800 Se Moberly Ln Bentonville AR 72712-7017
Phone: (479) 521-2752
Fax: (479) 521-4603
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Orthopaedic Surgery 207X00000X E5957 Arkansas
Allopathic & Osteopathic Physicians / Orthopaedic Surgery of the Spine 207XS0117X E5957 Arkansas

Profile Details

NPI number 1528173697
LBN Legal business name Randolph, Gannon B
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Aug 20th, 2006
Last updated Jul 12th, 2021 - about 3 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

Request for update

Identifiers

StateTypeNumberIssuer
All States NPI 1528173697 NPPES
Arkansas MEDICAID 1176259001

Popular Providers