Provider Demographics
NPI:1467410266
Name:HENNIGAR, RANDOLPH A (PHD, MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:A
Last Name:HENNIGAR
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF PATHOLOGY 101 NICOLLS RD BST-9T RM 140
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8691
Mailing Address - Country:US
Mailing Address - Phone:770-843-1990
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF PATHOLOGY 101 NICOLLS RD BST-9T RM 140
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-1059
Practice Address - Country:US
Practice Address - Phone:770-843-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307626207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF47309Medicare UPIN