Provider Demographics
NPI:1295711083
Name:WILLIAMS, RANDALL L (PT)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:WILLIAMS
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 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:
Practice Address - Street 1:4450 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1009538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159915401Medicaid
TX159915401Medicaid
TX8A5086Medicare PIN