Provider Demographics
NPI:1508858804
Name:HENTHORN, RANDALL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WAYNE
Last Name:HENTHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:
Practice Address - Street 1:750 NE 13TH ST
Practice Address - Street 2:OAC 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5010
Practice Address - Country:US
Practice Address - Phone:405-271-4351
Practice Address - Fax:405-271-8695
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11470208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
352500500OtherUS DEPT OF LAOR/OWCP
OK050080210OtherRAILROAD MEDICARE
OK731590295004OtherHUMANA MILITARY
OK731069171007OtherBLUE CROSS BLUE SHIELD
OK050080210OtherRAILROAD MEDICARE