Healthcare Provider Details

I. General information

NPI: 1295763183
Provider Name (Legal Business Name): RANDALL R PHILLIPS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 MONTGOMERY ST
FORT WORTH TX
76107-2553
US

IV. Provider business mailing address

PO BOX 99335
FORT WORTH TX
76199-0335
US

V. Phone/Fax

Practice location:
  • Phone: 817-735-5450
  • Fax: 817-735-5454
Mailing address:
  • Phone: 817-735-5450
  • Fax: 817-735-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberH6916
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: