Provider Demographics
NPI:1851429047
Name:RANDALL W. HENTHORN MD PC
Entity Type:Organization
Organization Name:RANDALL W. HENTHORN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HENTHORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-736-9331
Mailing Address - Street 1:520 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-5723
Mailing Address - Country:US
Mailing Address - Phone:405-736-9331
Mailing Address - Fax:405-736-0497
Practice Address - Street 1:520 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-5723
Practice Address - Country:US
Practice Address - Phone:405-736-9331
Practice Address - Fax:405-736-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731069171007OtherBLUE CROSS BLUE SHIELD
352500500OtherFEDERAL WORKERS COMP
OK050080210OtherRAILROAD MEDICARE
=========004OtherTRICARE PGBA
OK731069171007OtherBLUE CROSS BLUE SHIELD