Provider Demographics
NPI:1295918449
Name:STALEY, RANDALL DEAN JR (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DEAN
Last Name:STALEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:4700 S THOMPSON ST STE C103
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764
Practice Address - Country:US
Practice Address - Phone:479-571-6363
Practice Address - Fax:479-684-3941
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-63792084P0800X, 2084P0804X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE6379OtherSTATE LICENSE