Provider Demographics
NPI:1417452996
Name:RANDA, KRISTIN (DO)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:RANDA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1035
Mailing Address - Country:US
Mailing Address - Phone:414-454-8300
Mailing Address - Fax:239-343-2301
Practice Address - Street 1:2780 CLEVELAND AVE STE 709
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5857
Practice Address - Country:US
Practice Address - Phone:239-343-3831
Practice Address - Fax:239-343-2301
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17784207Q00000X
WI72836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110556500Medicaid