Provider Demographics
NPI:1194247395
Name:RANDALL, MARVIN SEAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:SEAN
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 JACOBY ST
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3025
Mailing Address - Country:US
Mailing Address - Phone:862-205-4931
Mailing Address - Fax:
Practice Address - Street 1:32 JACOBY ST
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3025
Practice Address - Country:US
Practice Address - Phone:862-205-4931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJA1473834171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach