Provider Demographics
NPI:1962467555
Name:UNDERWOOD, JOHN RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDALL
Last Name:UNDERWOOD
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 1:2669 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:575-434-0159
Mailing Address - Fax:888-687-6133
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 570
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4792
Practice Address - Country:US
Practice Address - Phone:575-434-0159
Practice Address - Fax:888-687-6133
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2019-0235207LP2900X
TN27431207L00000X, 207LP2900X, 208VP0014X
TNMD27431207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78176565Medicaid
TN3817322Medicaid
TN1513460Medicaid
TN3817322Medicaid