Provider Demographics
NPI:1457374621
Name:KIRTLEY, RANDALL WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WESLEY
Last Name:KIRTLEY
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 1:300 S COMMERCE ST
Mailing Address - Street 2:STE B
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-2760
Mailing Address - Country:US
Mailing Address - Phone:512-398-2331
Mailing Address - Fax:
Practice Address - Street 1:300 S COMMERCE ST
Practice Address - Street 2:STE B
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-2760
Practice Address - Country:US
Practice Address - Phone:512-398-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032793402Medicaid
TXTXB117649Medicare PIN
B23989Medicare UPIN