Provider Demographics
NPI:1639196108
Name:RANDALL, MICHAEL L (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720
Mailing Address - Country:US
Mailing Address - Phone:631-580-1740
Mailing Address - Fax:631-580-9155
Practice Address - Street 1:2539 MIDDLE COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-580-1740
Practice Address - Fax:631-580-9155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G67513Medicare UPIN
NY690223Medicare PIN
NY6902239101Medicare PIN