Provider Demographics
NPI:1225033574
Name:WAGMAN, RANDALL (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:
Last Name:WAGMAN
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 1:920 US HIGHWAY 287 N
Mailing Address - Street 2:STE 300
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2627
Mailing Address - Country:US
Mailing Address - Phone:817-539-0770
Mailing Address - Fax:817-539-0772
Practice Address - Street 1:920 HIGHWAY 287 N
Practice Address - Street 2:STE 300
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2627
Practice Address - Country:US
Practice Address - Phone:817-539-0770
Practice Address - Fax:817-539-0772
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2009-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11202R207Q00000X
TXM8410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197913001Medicaid
LA1667081Medicaid
5W380Medicare PIN
LA1667081Medicaid
TX8F9049Medicare PIN
LAG12160Medicare UPIN
5W3807460Medicare PIN