Healthcare Provider Details

I. General information

NPI: 1154304434
Provider Name (Legal Business Name): RANDY L NIBLETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 GENESEE STREET
UTICA NY
13501-5930
US

IV. Provider business mailing address

4567 CROSSROADS PARK DRIVE
LIVERPOOL NY
13088-3589
US

V. Phone/Fax

Practice location:
  • Phone: 315-798-8171
  • Fax: 315-734-3064
Mailing address:
  • Phone: 315-295-2100
  • Fax: 315-295-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME171857
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number262720
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24386
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: