Healthcare Provider Details

I. General information

NPI: 1235261082
Provider Name (Legal Business Name): RANDALL L SIMONSEN MD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 GENERAL CAVAZOS BLVD
KINGSVILLE TX
78363-7129
US

IV. Provider business mailing address

15210 CARTAGENA CT
CORPUS CHRISTI TX
78418-6914
US

V. Phone/Fax

Practice location:
  • Phone: 361-595-1661
  • Fax:
Mailing address:
  • Phone: 361-779-8813
  • Fax: 361-595-9895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberH8840
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: