Basic Information
| Provider Information | |||||||||
| NPI: | 1275969982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDEV | ||||||||
| FirstName: | PRABHJOT | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109227000 | ||||||||
| FaxNumber: | 2106372499 | ||||||||
| Practice Location | |||||||||
| Address1: | 5542 WALZEM RD | ||||||||
| Address2: | |||||||||
| City: | WINDCREST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782182103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109227000 | ||||||||
| FaxNumber: | 2106372499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R0105 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1275969982 | 01 | TX | NPI | OTHER |