Provider Demographics
NPI:1639372022
Name:RANDAZZO, JON JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:JOSEPH
Last Name:RANDAZZO
Suffix:
Gender:M
Credentials:DC
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 70160
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-0160
Mailing Address - Country:US
Mailing Address - Phone:718-843-7720
Mailing Address - Fax:
Practice Address - Street 1:10515 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-1809
Practice Address - Country:US
Practice Address - Phone:718-843-7720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007603-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5897310OtherGHI, GROUP HEALTH INC. #
NY20-3202120OtherNATIONAL HEALTH PLAN
NYCO 7603-1OtherNEW YORK WORKERS COMP
NYP41-5011OtherOXFORD
NYWXRTT1 X6314XRTT1Medicare PIN