Provider Demographics
NPI:1518946003
Name:PARK, RANDY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LYNN
Last Name:PARK
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 1:2040 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-3721
Mailing Address - Country:US
Mailing Address - Phone:940-383-3858
Mailing Address - Fax:940-566-0669
Practice Address - Street 1:24727 STATE HIGHWAY 249
Practice Address - Street 2:SUITE 120
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-7727
Practice Address - Country:US
Practice Address - Phone:281-516-0911
Practice Address - Fax:281-516-4511
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9923207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89194FOtherBCBS
TX89194FOtherBCBS
TXC20186Medicare UPIN