Healthcare Provider Details

I. General information

NPI: 1184653750
Provider Name (Legal Business Name): UDELE V. TAYLOR-RANDALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13176 LAURELTON PKWY
ROSEDALE NY
11422
US

IV. Provider business mailing address

176 HAZELWOOD DR
WESTBURY NY
11590-1212
US

V. Phone/Fax

Practice location:
  • Phone: 718-525-7125
  • Fax: 718-525-7126
Mailing address:
  • Phone: 516-338-5882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number174510
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: