Healthcare Provider Details

I. General information

NPI: 1134305311
Provider Name (Legal Business Name): RANDOLPH ROSARION M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12010 15TH AVE RM. 6
COLLEGE POINT NY
11356-1617
US

IV. Provider business mailing address

12010 15TH AVE RM. 6
COLLEGE POINT NY
11356-1617
US

V. Phone/Fax

Practice location:
  • Phone: 718-701-5949
  • Fax: 718-701-5949
Mailing address:
  • Phone: 718-701-5949
  • Fax: 718-701-5949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number201787
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number201787
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number201787
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: