Provider Demographics
NPI:1801854914
Name:BACULI, RANDI HERBOLARIO (MD)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:HERBOLARIO
Last Name:BACULI
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:PO BOX 940092
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75094-0092
Mailing Address - Country:US
Mailing Address - Phone:972-423-0977
Mailing Address - Fax:972-578-1867
Practice Address - Street 1:2504 FIGTREE LN
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-4858
Practice Address - Country:US
Practice Address - Phone:972-423-0977
Practice Address - Fax:972-578-1867
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL21172084N0400X
IN01051720A2084N0400X
DECI00061802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149294404Medicaid
TX8AJ227OtherBCBS
7477332OtherAETNA
TX149294403Medicaid
P00003881Medicare ID - Type UnspecifiedRAILROAD
7477332OtherAETNA
TX149294403Medicaid