Provider Demographics
NPI:1356476741
Name:RANDAZZO-BURTON, THERESA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RANDAZZO-BURTON
Suffix:
Gender:F
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3792
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1192892084P0804X
MA2187862084P0800X
NC2007016512084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910414Medicaid
NC5910414Medicaid