Provider Demographics
NPI:1114933678
Name:NORTHCUTT, ROY RANDALL
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:RANDALL
Last Name:NORTHCUTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 NORTH SIXTH
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601
Mailing Address - Country:US
Mailing Address - Phone:903-236-3202
Mailing Address - Fax:903-236-4894
Practice Address - Street 1:1201 NORTH SIXTH
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601
Practice Address - Country:US
Practice Address - Phone:903-236-3202
Practice Address - Fax:903-236-4894
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4022111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350025046OtherMEDICARE RAILROAD
350025046OtherMEDICARE RAILROAD
601332Medicare PIN