Provider Demographics
NPI:1578525093
Name:MAYERSON, RANDY C (MT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:C
Last Name:MAYERSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAUREEN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2934
Mailing Address - Country:US
Mailing Address - Phone:248-545-6963
Mailing Address - Fax:
Practice Address - Street 1:1311 MAUREEN AVE
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2934
Practice Address - Country:US
Practice Address - Phone:248-545-6963
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other