Basic Information
Provider Information | |||||||||
NPI: | 1255350757 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAYDEW | ||||||||
FirstName: | RANDALL | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 WELBORN ST | ||||||||
Address2: | #420 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752195201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4699640807 | ||||||||
FaxNumber: | 2143637036 | ||||||||
Practice Location | |||||||||
Address1: | 1819 DENVER WEST DR # 26-200 | ||||||||
Address2: |   | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 804013118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034229438 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 05/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | J0589 | TX | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 052955402 | 05 | TX |   | MEDICAID | 33605 | 05 | TX |   | MEDICAID |