Provider Demographics
NPI:1316929961
Name:GRIMSHAW, RANDALL J (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:GRIMSHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W OLLIE ST
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:TX
Mailing Address - Zip Code:78643-2628
Mailing Address - Country:US
Mailing Address - Phone:325-247-5040
Mailing Address - Fax:325-247-2801
Practice Address - Street 1:200 W OLLIE ST
Practice Address - Street 2:
Practice Address - City:LLANO
Practice Address - State:TX
Practice Address - Zip Code:78643-2628
Practice Address - Country:US
Practice Address - Phone:325-247-5040
Practice Address - Fax:325-247-2801
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F9846OtherBCBS
TX101840100OtherFIRST CARE
TX135408609Medicaid
TXTXB127464Medicare PIN
TX101840100OtherFIRST CARE
C16325Medicare UPIN