Provider Demographics
NPI:1881408854
Name:SMITH, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
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 1:2922 SKYWAY CIR N
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3509
Mailing Address - Country:US
Mailing Address - Phone:972-514-1926
Mailing Address - Fax:972-887-3058
Practice Address - Street 1:2922 SKYWAY CIR N
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-7503
Practice Address - Country:US
Practice Address - Phone:972-514-1926
Practice Address - Fax:972-887-3058
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WV0202XOther Service ProvidersContractorVehicle ModificationsGroup - Single Specialty