Provider Demographics
NPI:1497956700
Name:RANDLES, RYAN TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TIMOTHY
Last Name:RANDLES
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:DEPT 96-0390
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0390
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:
Practice Address - Street 1:231 S COLLINS RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4624
Practice Address - Country:US
Practice Address - Phone:972-203-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4025207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0026732OtherINSTITUTIONAL PERMIT
TX205875203Medicaid
TX205875203Medicaid