Provider Demographics
NPI:1164476743
Name:RANDHAWA, M TARIQ (MD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:TARIQ
Last Name:RANDHAWA
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 1:411 CANISTEO ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-2104
Mailing Address - Country:US
Mailing Address - Phone:607-324-8000
Mailing Address - Fax:
Practice Address - Street 1:411 CANISTEO ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-2104
Practice Address - Country:US
Practice Address - Phone:607-324-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116454-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00459123Medicaid
NYD07492Medicare UPIN
NY00459123Medicaid