Provider Demographics
NPI:1841384690
Name:HARDEE, GARY RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RANDALL
Last Name:HARDEE
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 1:300 W HALSELL ST
Mailing Address - Street 2:
Mailing Address - City:DIMMITT
Mailing Address - State:TX
Mailing Address - Zip Code:79027-1846
Mailing Address - Country:US
Mailing Address - Phone:806-647-2194
Mailing Address - Fax:806-647-3769
Practice Address - Street 1:300 W HALSELL ST
Practice Address - Street 2:
Practice Address - City:DIMMITT
Practice Address - State:TX
Practice Address - Zip Code:79027-1846
Practice Address - Country:US
Practice Address - Phone:806-647-2194
Practice Address - Fax:806-647-3769
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114547102OtherFIRSTCARE
TX130796901Medicaid
TX458679OtherMEDICARE GROUP
TX00GE14OtherBLUE CROSS BLUE SHIELD
TX130796901Medicaid
TX114547102OtherFIRSTCARE