Provider Demographics
NPI:1003847716
Name:RANDALL, RANDY CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:CRAIG
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 702620
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-2620
Mailing Address - Country:US
Mailing Address - Phone:888-608-7999
Mailing Address - Fax:512-331-1605
Practice Address - Street 1:1783 TROUP HIGHWAY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-595-2283
Practice Address - Fax:903-595-1063
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9993207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128175006Medicaid
P00044309OtherMEDICARE RR
C20844Medicare UPIN
P00044309Medicare PIN
TX128175006Medicaid
TX8A9579Medicare PIN