Provider Demographics
NPI:1639218415
Name:MARTIN, RANDALL WARREN (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WARREN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 OVERRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1249
Mailing Address - Country:US
Mailing Address - Phone:817-795-5855
Mailing Address - Fax:817-795-9330
Practice Address - Street 1:3343 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-4603
Practice Address - Country:US
Practice Address - Phone:817-795-5855
Practice Address - Fax:817-795-9330
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC 5932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX605953OtherBLUECROSS BLUESHIELD
TX609231Medicare ID - Type Unspecified
TXU35142Medicare UPIN