Healthcare Provider Details

I. General information

NPI: 1457374621
Provider Name (Legal Business Name): RANDALL WESLEY KIRTLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S COMMERCE ST STE B
LOCKHART TX
78644-2760
US

IV. Provider business mailing address

300 S COMMERCE ST STE B
LOCKHART TX
78644-2760
US

V. Phone/Fax

Practice location:
  • Phone: 512-398-2331
  • Fax:
Mailing address:
  • Phone: 512-398-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG8216
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: