Provider Demographics
NPI:1629178843
Name:RAMIREZ, RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:
Last Name:RAMIREZ
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 1:68 WEPAWAUG RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2423
Mailing Address - Country:US
Mailing Address - Phone:203-298-9309
Mailing Address - Fax:
Practice Address - Street 1:2103 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06115
Practice Address - Country:US
Practice Address - Phone:203-377-3666
Practice Address - Fax:203-377-6500
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT031878OtherSTATE LICENSE
CT001318783Medicaid
CTF99489Medicare UPIN