Provider Demographics
NPI:1760550073
Name:RANDALL, DEREK GLOVER (MD)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:GLOVER
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7 FORDHAM HILL OVAL
Mailing Address - Street 2:APT #14A & H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-4835
Mailing Address - Country:US
Mailing Address - Phone:718-733-3636
Mailing Address - Fax:
Practice Address - Street 1:7 FORDHAM HILL OVAL
Practice Address - Street 2:APT #14A & H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-4835
Practice Address - Country:US
Practice Address - Phone:718-733-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1239652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C12178Medicare UPIN
84D901Medicare ID - Type Unspecified