Provider Demographics
NPI:1730192964
Name:KIMMELMAN, RANDY SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:SCOTT
Last Name:KIMMELMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3467 W HILLSBORO BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-9473
Mailing Address - Country:US
Mailing Address - Phone:954-574-0252
Mailing Address - Fax:954-429-1759
Practice Address - Street 1:3467 W HILLSBORO BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-9473
Practice Address - Country:US
Practice Address - Phone:954-574-0252
Practice Address - Fax:954-429-1759
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7449208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252588700Medicaid
FL57516UOtherMEDICARE - FL
FL57516OtherBCBS OF FLORIDA
FL241859OtherAVMED
FL252588700Medicaid