Provider Demographics
NPI:1093928715
Name:SILLER, RANDALL ERIC (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ERIC
Last Name:SILLER
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 1:2631 CENTER COURT DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332-1832
Mailing Address - Country:US
Mailing Address - Phone:954-217-8394
Mailing Address - Fax:954-432-6905
Practice Address - Street 1:10041 PINES BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6170
Practice Address - Country:US
Practice Address - Phone:954-432-6677
Practice Address - Fax:954-432-6905
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4734208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82646Medicare UPIN
FLE32284Medicare ID - Type Unspecified