Provider Demographics
NPI:1063477552
Name:MCKENNA, RANDALL WADE (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WADE
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 S FM 51
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234
Mailing Address - Country:US
Mailing Address - Phone:940-627-6976
Mailing Address - Fax:940-627-3491
Practice Address - Street 1:1713 S FM 51
Practice Address - Street 2:SUITE 103
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234
Practice Address - Country:US
Practice Address - Phone:940-627-6976
Practice Address - Fax:940-627-3491
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0118207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131938605Medicaid
TX89Z590OtherBCBSTX
TX131938605Medicaid