Provider Demographics
NPI:1356364376
Name:GRELLNER, RANDY JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JAMES
Last Name:GRELLNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:RANDALL
Other - Middle Name:JAMES
Other - Last Name:GRELLNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1025 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4136
Mailing Address - Country:US
Mailing Address - Phone:918-225-3627
Mailing Address - Fax:918-225-1008
Practice Address - Street 1:1025 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4136
Practice Address - Country:US
Practice Address - Phone:918-225-3627
Practice Address - Fax:918-225-1008
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100137700BMedicaid
249424702Medicare ID - Type Unspecified
OK100137700BMedicaid