Provider Demographics
NPI:1336173632
Name:SMITH, RANDY LEE
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 SE LOOP 820
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-1019
Mailing Address - Country:US
Mailing Address - Phone:817-590-8166
Mailing Address - Fax:817-590-8277
Practice Address - Street 1:2908 SE LOOP 820
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-1019
Practice Address - Country:US
Practice Address - Phone:817-590-8166
Practice Address - Fax:817-590-8277
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2016-03-14
Deactivation Date:2011-09-08
Deactivation Code:
Reactivation Date:2016-03-14
Provider Licenses
StateLicense IDTaxonomies
TX421484921332B00000X
TX332B00000X, 332BC3200X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1872004-03Medicaid
TX1872004-05Medicaid
TX1872004-01Medicaid
TX1872004-01Medicaid