Provider Demographics
NPI:1588636013
Name:RAINE, RANDALL (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:RAINE
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:PO BOX 947407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:842 SUNSET LAKE BLVD STE 401
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7553
Practice Address - Country:US
Practice Address - Phone:941-261-7880
Practice Address - Fax:941-261-7888
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3486207R00000X
FLOS19288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicare PIN
OKG94900Medicare UPIN