Provider Demographics
NPI:1538462346
Name:TREADWELL, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:TREADWELL
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 1:11601 SHADOW CREEK PKWY
Mailing Address - Street 2:#111-104
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7283
Mailing Address - Country:US
Mailing Address - Phone:325-829-0894
Mailing Address - Fax:
Practice Address - Street 1:11601 SHADOW CREEK PKWY
Practice Address - Street 2:#111-104
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7283
Practice Address - Country:US
Practice Address - Phone:325-829-0894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2073207Q00000X
MOR5P88207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0353583-01Medicaid
TX00PK61OtherMEDICARE PROVIDER NUMBER