Provider Demographics
NPI:1437430717
Name:LUCIOUS RANDLE JR MDPA
Entity Type:Organization
Organization Name:LUCIOUS RANDLE JR MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:DONATTO
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR ASSISTANT
Authorized Official - Phone:713-526-1872
Mailing Address - Street 1:1213 HERMANN DR
Mailing Address - Street 2:SUITE 415
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-7018
Mailing Address - Country:US
Mailing Address - Phone:713-526-1872
Mailing Address - Fax:713-526-2515
Practice Address - Street 1:1213 HERMANN DR
Practice Address - Street 2:SUITE 415
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-7018
Practice Address - Country:US
Practice Address - Phone:713-526-1872
Practice Address - Fax:713-526-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4408207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC20847Medicare UPIN