Provider Demographics
NPI:1235136938
Name:SMITH, RANDY WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:WALLACE
Last Name:SMITH
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 1:1602 ROCK PRAIRIE RD
Mailing Address - Street 2:#430
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8306
Mailing Address - Country:US
Mailing Address - Phone:979-693-0737
Mailing Address - Fax:979-693-7442
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:#430
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:979-693-0737
Practice Address - Fax:979-693-7442
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3802207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115736401Medicaid
TX82G527Medicare ID - Type Unspecified
TX115736401Medicaid