Healthcare Provider Details

I. General information

NPI: 1003847716
Provider Name (Legal Business Name): RANDY CRAIG RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1783 TROUP HIGHWAY
TYLER TX
75701
US

IV. Provider business mailing address

PO BOX 702620
TULSA OK
74170-2620
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-2283
  • Fax: 903-595-1063
Mailing address:
  • Phone: 888-608-7999
  • Fax: 512-331-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberF9993
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: