Provider Demographics
NPI:1134165103
Name:DAVIS, RANDEL BRAD (PT)
Entity type:Individual
Prefix:
First Name:RANDEL
Middle Name:BRAD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT
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 57710
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-7710
Mailing Address - Country:US
Mailing Address - Phone:405-258-8644
Mailing Address - Fax:405-240-5145
Practice Address - Street 1:112 N BLAINE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-1223
Practice Address - Country:US
Practice Address - Phone:405-258-8644
Practice Address - Fax:405-240-5145
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist