Provider Demographics
NPI:1467492363
Name:HARTMAN, RANDY G (DPM)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:G
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 S LEE POINT RD
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9526
Mailing Address - Country:US
Mailing Address - Phone:231-271-5210
Mailing Address - Fax:
Practice Address - Street 1:620 WOODMERE AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3397
Practice Address - Country:US
Practice Address - Phone:231-946-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRH001180213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2879030Medicaid
MIOB86034002Medicare ID - Type Unspecified
MI2879030Medicaid