Provider Demographics
NPI:1225046865
Name:GARY M. RANDALL, D.O.,P.A.
Entity Type:Organization
Organization Name:GARY M. RANDALL, D.O.,P.A.
Other - Org Name:RANDALL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:936-637-2080
Mailing Address - Street 1:1 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3173
Mailing Address - Country:US
Mailing Address - Phone:936-637-2080
Mailing Address - Fax:936-637-7917
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3173
Practice Address - Country:US
Practice Address - Phone:936-637-2080
Practice Address - Fax:936-637-7917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080005401Medicaid
00150NMedicare PIN