Provider Demographics
NPI:1487653358
Name:WOLCOTT, RANDALL D (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:WOLCOTT
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 1:2002 OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1025
Mailing Address - Country:US
Mailing Address - Phone:806-793-8869
Mailing Address - Fax:806-793-0043
Practice Address - Street 1:2002 OXFORD AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1025
Practice Address - Country:US
Practice Address - Phone:806-793-8869
Practice Address - Fax:806-793-0043
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6248208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB27648Medicare UPIN
TX8094B0Medicare PIN