Provider Demographics
NPI:1225393275
Name:HENDERSON, RANDALL L (DO)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 W CAMELLIA WAY
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-1348
Mailing Address - Country:US
Mailing Address - Phone:405-314-5420
Mailing Address - Fax:
Practice Address - Street 1:1208 W CAMELLIA WAY
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-1348
Practice Address - Country:US
Practice Address - Phone:405-314-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5228207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine