Basic Information
Provider Information | |||||||||
NPI: | 1841262003 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | RANDY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 S. PARK ST. | ||||||||
Address2: | PO BOX 130 | ||||||||
City: | CLAUDE | ||||||||
State: | TX | ||||||||
PostalCode: | 790190130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062265611 | ||||||||
FaxNumber: | 8062266703 | ||||||||
Practice Location | |||||||||
Address1: | 201 S. PARK ST. | ||||||||
Address2: |   | ||||||||
City: | CLAUDE | ||||||||
State: | TX | ||||||||
PostalCode: | 790190130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062265611 | ||||||||
FaxNumber: | 8062266703 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2006 | ||||||||
LastUpdateDate: | 07/08/2015 | ||||||||
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 | 207R00000X | G8442 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000X9521 | 05 | NM |   | MEDICAID | 100179660 A | 05 | OK |   | MEDICAID | 063682101 | 05 | TX |   | MEDICAID | 1371858015 | 05 | TX |   | MEDICAID |