Healthcare Provider Details

I. General information

NPI: 1366436818
Provider Name (Legal Business Name): RANDOLPH S MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WEBSTER AVE STE 202
POUGHKEEPSIE NY
12601-1362
US

IV. Provider business mailing address

1 WEBSTER AVE STE 202
POUGHKEEPSIE NY
12601-1362
US

V. Phone/Fax

Practice location:
  • Phone: 845-483-5934
  • Fax:
Mailing address:
  • Phone: 845-483-5934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number155943
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036079474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: