Provider Demographics
NPI:1629103619
Name:RANDEL, MARK ALFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALFORD
Last Name:RANDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 630668
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-0668
Mailing Address - Country:US
Mailing Address - Phone:936-568-9993
Mailing Address - Fax:936-568-9996
Practice Address - Street 1:3618 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2539
Practice Address - Country:US
Practice Address - Phone:936-568-9993
Practice Address - Fax:936-568-9996
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH65292086S0129X, 208600000X
OK169512086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030062603Medicaid
TX00323JOtherBLUE CROSS BLUE SHIELD
TX030062604Medicaid
TX030062602Medicaid
TX8CN590OtherBLUE CROSS BLUE SHIELD
TXTXB114937Medicare PIN
TX030062602Medicaid
TX030062603Medicaid