Provider Demographics
NPI:1255400099
Name:BURD, RANDALL
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:BURD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:CLINICAL ACADEMIC BUILDING - SUITE 4100
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA721902086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG53060Medicare UPIN
NJ8533202Medicare ID - Type Unspecified
NJ049306C5XMedicare PIN