1336713213 NPI number — RANDEE KATHRYN WALCK-COETZEE MD

Table of content: RANDEE KATHRYN WALCK-COETZEE MD (NPI 1336713213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336713213 NPI number — RANDEE KATHRYN WALCK-COETZEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALCK-COETZEE
Provider First Name:
RANDEE
Provider Middle Name:
KATHRYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALCK
Provider Other First Name:
RANDEE
Provider Other Middle Name:
KATHRYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336713213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15409 SE 49TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHOCTAUW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-618-7793
Provider Business Mailing Address Fax Number:
405-272-6985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 W. WRANGLER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEMINOLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-382-3650
Provider Business Practice Location Address Fax Number:
405-382-9848
Provider Enumeration Date:
05/17/2021

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 38438 , 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)





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