Provider Demographics
NPI:1780733360
Name:SOLOMON, RANDALL
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:SOLOMON
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 1:55 NESCONSET HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2631
Mailing Address - Country:US
Mailing Address - Phone:631-474-8099
Mailing Address - Fax:
Practice Address - Street 1:55 NESCONSET HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2631
Practice Address - Country:US
Practice Address - Phone:631-474-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1747112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01112610Medicaid
NY07F841Medicare UPIN
NY01112610Medicaid