Provider Demographics
NPI:1124844980
Name:RANDLOV, CASEY (NP)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:RANDLOV
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CAMPBELL LN
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3621
Mailing Address - Country:US
Mailing Address - Phone:631-357-6398
Mailing Address - Fax:
Practice Address - Street 1:1 PENN PLZ FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0899
Practice Address - Country:US
Practice Address - Phone:866-234-8913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311881-01207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine