Provider Demographics
NPI:1285685511
Name:MAUFFRAY, RANDY OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:OWEN
Last Name:MAUFFRAY
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 1:800 MCCULLOUGH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215
Mailing Address - Country:US
Mailing Address - Phone:210-226-6169
Mailing Address - Fax:210-226-8365
Practice Address - Street 1:800 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1625
Practice Address - Country:US
Practice Address - Phone:210-226-6169
Practice Address - Fax:210-226-8365
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6232207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369304601Medicaid
TX517769Medicare PIN