Provider Demographics
NPI: | 1245231885 |
---|---|
Name: | BROWN, WILLIAM RANDALL (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | WILLIAM |
Middle Name: | RANDALL |
Last Name: | BROWN |
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: | PO BOX 1325 |
Mailing Address - Street 2: | |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46206-1325 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-792-1292 |
Mailing Address - Fax: | 903-792-2051 |
Practice Address - Street 1: | 5508 SUMMERHILL RD |
Practice Address - Street 2: | |
Practice Address - City: | TEXARKANA |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75503-1822 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-792-1292 |
Practice Address - Fax: | 903-792-2051 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-04 |
Last Update Date: | 2013-09-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | G1862 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 103364901 | Medicaid | |
TX | 300032042 | Other | RAILROAD MEDICARE |
TX | 751708760 | Other | EIN |
TX | 82R610 | Medicare ID - Type Unspecified | |
TX | D48012 | Medicare UPIN | |
TX | 103364901 | Medicaid |