Provider Demographics
NPI:1700862919
Name:RANDAZZO, DOMENICK N (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMENICK
Middle Name:N
Last Name:RANDAZZO
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:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-1735
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:8 TEMPE WICK RD
Practice Address - Street 2:
Practice Address - City:MENDHAM
Practice Address - State:NJ
Practice Address - Zip Code:07945-1814
Practice Address - Country:US
Practice Address - Phone:973-543-2288
Practice Address - Fax:973-543-0637
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA56798174400000X
NJ25MA05679800207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7248806Medicaid
NJ7248806Medicaid
NJG20164Medicare UPIN