Provider Demographics
NPI:1780888008
Name:RANDALL K. DAVIS, M.D.,P.A.
Entity type:Organization
Organization Name:RANDALL K. DAVIS, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-689-2222
Mailing Address - Street 1:4214 ANDREWS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4822
Mailing Address - Country:US
Mailing Address - Phone:432-689-2222
Mailing Address - Fax:432-689-3430
Practice Address - Street 1:4214 ANDREWS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4822
Practice Address - Country:US
Practice Address - Phone:432-689-2222
Practice Address - Fax:432-689-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3081174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128434103Medicaid
TX128434103Medicaid
TX00K21EMedicare ID - Type Unspecified