Provider Demographics
NPI:1104205343
Name:RANDDOLF, DERRICK (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:RANDDOLF
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24165 W INTERSTATE 10 STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1160
Mailing Address - Country:US
Mailing Address - Phone:726-225-2290
Mailing Address - Fax:281-845-7063
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-703-5375
Practice Address - Fax:432-703-5238
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4622207P00000X, 207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine