Provider Demographics
NPI:1740219682
Name:A RANDALL MOODY II MD PA
Entity Type:Organization
Organization Name:A RANDALL MOODY II MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:830-285-4096
Mailing Address - Street 1:5788 ECKHERT RD
Mailing Address - Street 2:FRANK M. TEJEDA VA OUTPATIENT CLINIC, C& P DEPARTMENT
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3900
Mailing Address - Country:US
Mailing Address - Phone:830-285-4096
Mailing Address - Fax:830-896-3310
Practice Address - Street 1:5788 ECKHERT RD
Practice Address - Street 2:FRANK M. TEJEDA VA OUTPATIENT CLINIC, C&P DEPARTMENT
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3900
Practice Address - Country:US
Practice Address - Phone:830-285-4096
Practice Address - Fax:830-896-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2013-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178696401Medicaid
C19503Medicare UPIN
TX00877ZMedicare PIN
TX8F1823Medicare PIN