Provider Demographics
NPI:1730272675
Name:EPPERSON, RANDALL CRAIG (PHD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:CRAIG
Last Name:EPPERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 I STREET
Mailing Address - Street 2:SUITE 440
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354
Mailing Address - Country:US
Mailing Address - Phone:209-523-0999
Mailing Address - Fax:209-529-9671
Practice Address - Street 1:1601 I STREET
Practice Address - Street 2:SUITE 440
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354
Practice Address - Country:US
Practice Address - Phone:209-523-0999
Practice Address - Fax:209-529-9671
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8723103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY-087230Medicaid
CAPSY-087230Medicaid
CA00PL-87230Medicare ID - Type Unspecified