Provider Demographics
NPI:1477510972
Name:ERWIN, DAVID RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RANDOLPH
Last Name:ERWIN
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:817-321-0486
Practice Address - Street 1:2901 N 4TH ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5128
Practice Address - Country:US
Practice Address - Phone:903-663-9074
Practice Address - Fax:903-663-7394
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF39362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132275205Medicaid
TX80R926Medicare ID - Type Unspecified
TX132275205Medicaid