Provider Demographics
NPI:1255302360
Name:BRADDOM, RANDALL L (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:BRADDOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 GOLDEN GROVE DR
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-4023
Mailing Address - Country:US
Mailing Address - Phone:908-601-7036
Mailing Address - Fax:352-561-4512
Practice Address - Street 1:1093 GOLDEN GROVE DR
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-4023
Practice Address - Country:US
Practice Address - Phone:908-601-7036
Practice Address - Fax:352-561-4512
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02637400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9074201Medicaid
NJA71391Medicare UPIN
NJ067334BWOMedicare ID - Type Unspecified