Healthcare Provider Details

I. General information

NPI: 1124114301
Provider Name (Legal Business Name): RANDAL R STAVINOHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 W HOLCOMBE BLVD
HOUSTON TX
77025-1669
US

IV. Provider business mailing address

2727 W HOLCOMBE BLVD
HOUSTON TX
77025-1669
US

V. Phone/Fax

Practice location:
  • Phone: 713-442-0000
  • Fax:
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberJ2355
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: