Provider Demographics
NPI:1235261082
Name:SIMONSEN, RANDALL L (MD PA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:SIMONSEN
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15210 CARTAGENA CT
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-6914
Mailing Address - Country:US
Mailing Address - Phone:361-779-8813
Mailing Address - Fax:361-595-9895
Practice Address - Street 1:1311 GENERAL CAVAZOS BLVD
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7129
Practice Address - Country:US
Practice Address - Phone:361-595-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8840207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U07WMedicaid
P000U07W0Medicare ID - Type Unspecified
TX00U07WMedicaid