Provider Demographics
NPI:1679818595
Name:RANDALL L SIMONSEN MD PA
Entity Type:Organization
Organization Name:RANDALL L SIMONSEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMONSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-779-8813
Mailing Address - Street 1:15210 CARTAGENA CT
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-6914
Mailing Address - Country:US
Mailing Address - Phone:361-779-8813
Mailing Address - Fax:
Practice Address - Street 1:1311 EAST GENERAL CAVAZOS
Practice Address - Street 2:CHRISTUS SPOHN HOSPITAL KLEBERG
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363
Practice Address - Country:US
Practice Address - Phone:361-595-7979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8840207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1235261082OtherNPI (TYPE 1)
TX123989901Medicaid
TX123989901Medicaid