Provider Demographics
NPI:1881663979
Name:RANDAZZO, GUY P (MD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:P
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 15090
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92803-5090
Mailing Address - Country:US
Mailing Address - Phone:714-577-2124
Mailing Address - Fax:714-577-2125
Practice Address - Street 1:13522 NEWPORT AVE STE 102
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3707
Practice Address - Country:US
Practice Address - Phone:714-573-8200
Practice Address - Fax:714-573-9401
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22452207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB292883Medicaid
CA1912919804Medicaid
CA1912919804OtherNPI - TYPE 2
CA290003377OtherRAIL ROAD MEDICARE PROVIDER PTAN
CAW1514OtherMEDICARE PTAN - TYPE 2
CACG5665OtherRAIL ROAD MEDICARE - GROUP PTAN
CAW1514BOtherMEDICARE PTAN - TYPE 2
CAW1514BOtherMEDICARE PTAN - TYPE 2
CAW1514OtherMEDICARE PTAN - TYPE 2