Provider Demographics
NPI:1972944312
Name:GONZALES, RANDY M (LAC,LMT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:M
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LAC,LMT
Other - Prefix:MR
Other - First Name:RANDY
Other - Middle Name:M
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:999 OLD MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-2829
Mailing Address - Country:US
Mailing Address - Phone:631-875-7200
Mailing Address - Fax:
Practice Address - Street 1:999 OLD MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2829
Practice Address - Country:US
Practice Address - Phone:631-875-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005079-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist