Provider Demographics
NPI:1386820793
Name:SUNDERLAND, RANDALL LEE
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:SUNDERLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-7817
Mailing Address - Country:US
Mailing Address - Phone:830-768-2582
Mailing Address - Fax:830-768-0992
Practice Address - Street 1:707 E 17TH ST
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-7817
Practice Address - Country:US
Practice Address - Phone:830-768-2582
Practice Address - Fax:830-768-0992
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676507Medicare Oscar/Certification