Healthcare Provider Details

I. General information

NPI: 1164476743
Provider Name (Legal Business Name): M TARIQ RANDHAWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CANISTEO ST
HORNELL NY
14843-2104
US

IV. Provider business mailing address

411 CANISTEO ST
HORNELL NY
14843-2104
US

V. Phone/Fax

Practice location:
  • Phone: 607-324-8000
  • Fax:
Mailing address:
  • Phone: 607-324-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number116454-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: