Provider Demographics
NPI:1639100191
Name:KIRILUK, RANDY M (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:M
Last Name:KIRILUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10609 LUCAYA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3666
Mailing Address - Country:US
Mailing Address - Phone:843-742-9888
Mailing Address - Fax:813-973-0839
Practice Address - Street 1:10609 LUCAYA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3666
Practice Address - Country:US
Practice Address - Phone:843-742-9888
Practice Address - Fax:813-973-0839
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111950207Q00000X
GA85057207Q00000X
NC200801162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909978Medicaid
TN3882947Medicaid
TN4101598OtherBLUE CROSS
TN4101599OtherBLUE CROSS
TNP00343209OtherRAILROAD MEDICARE
TN3882949Medicaid
TNP00254455OtherRAILROAD MEDICARE
TN4101598OtherBLUE CROSS
TN3882947Medicaid
TN3882947Medicare PIN
NC5909978Medicaid