Provider Demographics
NPI:1871779090
Name:RANDALL D HENDERSON DO PA
Entity type:Organization
Organization Name:RANDALL D HENDERSON DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-694-2221
Mailing Address - Street 1:202 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-2398
Mailing Address - Country:US
Mailing Address - Phone:254-694-2221
Mailing Address - Fax:254-694-9978
Practice Address - Street 1:202 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-2398
Practice Address - Country:US
Practice Address - Phone:254-694-2221
Practice Address - Fax:254-694-9978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00925UOtherBCBS GROUP
TX159120801Medicaid
TX00925UOtherBCBS GROUP
TX00925UMedicare PIN