Provider Demographics
NPI:1003101403
Name:ESTWICK, RANDOLPH R (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:R
Last Name:ESTWICK
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 1:20 BLANCH AVE.
Mailing Address - Street 2:E-20
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640
Mailing Address - Country:US
Mailing Address - Phone:201-750-9339
Mailing Address - Fax:
Practice Address - Street 1:20 BLANCH AVE.
Practice Address - Street 2:E-20
Practice Address - City:HARRINGTON PARK
Practice Address - State:NJ
Practice Address - Zip Code:07640
Practice Address - Country:US
Practice Address - Phone:201-750-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02287300208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC-12529Medicare UPIN