Provider Demographics
NPI:1811988223
Name:STICKNEY, RANDALL HARWOOD (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:HARWOOD
Last Name:STICKNEY
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:PO BOX 4939
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74159-0939
Mailing Address - Country:US
Mailing Address - Phone:918-747-4975
Mailing Address - Fax:918-743-9058
Practice Address - Street 1:4111 S DARLINGTON AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6348
Practice Address - Country:US
Practice Address - Phone:918-747-4975
Practice Address - Fax:918-743-9058
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK163182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100147200AMedicaid
OKOK403012Medicare PIN
OK100147200AMedicaid
OKTULSX105Medicare PIN
OK300019577Medicare PIN
OKTULSX105Medicare Oscar/Certification