Provider Demographics
NPI:1164581682
Name:REINERTSON, RANDAL CORWIN (MD)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:CORWIN
Last Name:REINERTSON
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 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-772-4185
Mailing Address - Fax:409-772-6507
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-2382
Practice Address - Country:US
Practice Address - Phone:409-772-4182
Practice Address - Fax:409-772-6507
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40217207R00000X
TXM2768207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179219401Medicaid
TXI17586Medicare UPIN
TX179219401Medicaid