Provider Demographics
NPI:1154304434
Name:NIBLETT, RANDY L (MD)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:L
Last Name:NIBLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4567 CROSSROADS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:2209 GENESEE STREET
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5930
Practice Address - Country:US
Practice Address - Phone:315-798-8171
Practice Address - Fax:315-734-3064
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1718572085R0202X
NY2627202085R0202X
OK243862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200057370AMedicaid
OK248523231OtherMEDICARE
OKP000274709OtherRAILROAD MEDICARE
OKI00012Medicare UPIN
OK248523231OtherMEDICARE