Provider Demographics
NPI:1659483873
Name:GARDELL, RANDY C (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:C
Last Name:GARDELL
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 1:205 WOODHEW DR STE 110
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6689
Mailing Address - Country:US
Mailing Address - Phone:254-399-9291
Mailing Address - Fax:254-399-8414
Practice Address - Street 1:205 WOODHEW DR STE 110
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6689
Practice Address - Country:US
Practice Address - Phone:254-399-9291
Practice Address - Fax:254-399-8414
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH23952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00J26AMedicare ID - Type UnspecifiedGROUP NUMBER
G03641Medicare UPIN
87M034Medicare ID - Type UnspecifiedINDIVIDUAL