Provider Demographics
NPI:1104852888
Name:RODGERS, RANDALL W (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:W
Last Name:RODGERS
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 1:403 STATE HIGHWAY 110 N
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-3109
Mailing Address - Country:US
Mailing Address - Phone:903-839-1000
Mailing Address - Fax:903-839-4000
Practice Address - Street 1:403 STATE HIGHWAY 110 N
Practice Address - Street 2:
Practice Address - City:WHITEHOUSE
Practice Address - State:TX
Practice Address - Zip Code:75791-3109
Practice Address - Country:US
Practice Address - Phone:903-839-1000
Practice Address - Fax:903-839-4000
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0020208VP0014X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V0490OtherBCBSTX
TXP00342603OtherRAILROAD MEDICARE
TX43848OtherSTERLING
TX1104852888OtherBCBSTX
TX1287773-08Medicaid
TX663166OtherSTERLING MEDICARE ADVANTAGE
TX8F2821Medicare PIN
TX663166OtherSTERLING MEDICARE ADVANTAGE