Provider Demographics
NPI:1104205343
Name:RANDDOLF, DERRICK (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:RANDDOLF
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 1:701 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5375
Mailing Address - Fax:432-703-5238
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-703-5375
Practice Address - Fax:432-703-5238
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR4622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program