Provider Demographics
NPI:1831101328
Name:RANDALL, ALFRED B (MD)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:B
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 PORT WASHINGTON BLVD
Mailing Address - Street 2:SUITE 101 VIZZA PAVILLION
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1353
Mailing Address - Country:US
Mailing Address - Phone:516-627-4820
Mailing Address - Fax:516-627-6524
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:SUITE 101 VIZZA PAVILLION
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-627-4820
Practice Address - Fax:516-627-6524
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY112203207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C07804Medicare UPIN
285231Medicare ID - Type Unspecified