MEDICARE: DR. RANDY WALLACE SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	G3802	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235136938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY WALLACE SMITH M.D.

Provider Business Mailing Address
First Line	:	1602 ROCK PRAIRIE RD
Second Line	:	#430
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-8306
Country	:	US
Telephone Number	:	979-693-0737
Fax Number	:	979-693-7442

Provider Business Practice Location Address
First Line	:	1602 ROCK PRAIRIE RD
Second Line	:	#430
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-8306
Country	:	US
Telephone Number	:	979-693-0737
Fax Number	:	979-693-7442

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	02/14/2014

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