1033250212 NPI number — MR. RANDALL SHANE MYERS

Table of content: MR. RANDALL SHANE MYERS (NPI 1033250212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033250212 NPI number — MR. RANDALL SHANE MYERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYERS
Provider First Name:
RANDALL
Provider Middle Name:
SHANE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KING
Provider Other First Name:
ROY
Provider Other Middle Name:
RUSSELL
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPED
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1033250212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 S 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNCAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73533-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-470-9490
Provider Business Mailing Address Fax Number:
580-470-9502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 S 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNCAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73533-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-470-9490
Provider Business Practice Location Address Fax Number:
580-470-9502
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  13-D-1200 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201453400001 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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