Provider Demographics
NPI:1710910740
Name:RICHWINE, RANDALL T (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:T
Last Name:RICHWINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 W VICKERY BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7448
Mailing Address - Country:US
Mailing Address - Phone:817-732-2878
Mailing Address - Fax:817-732-0648
Practice Address - Street 1:5750 W VICKERY BLVD STE 104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7448
Practice Address - Country:US
Practice Address - Phone:817-732-2878
Practice Address - Fax:817-732-0648
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160039703Medicaid
TX160039706Medicaid
TX160039706Medicaid
TXTXB122154Medicare PIN
TXH48981Medicare UPIN