Provider Demographics
NPI:1942387428
Name:BOODRAM, KRANSTON G (OD)
Entity Type:Individual
Prefix:
First Name:KRANSTON
Middle Name:G
Last Name:BOODRAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1407
Mailing Address - Country:US
Mailing Address - Phone:407-893-8200
Mailing Address - Fax:407-893-8220
Practice Address - Street 1:1911 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1407
Practice Address - Country:US
Practice Address - Phone:407-893-8200
Practice Address - Fax:407-893-8220
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20850VMedicare PIN
FL20850UMedicare PIN
FL20850YMedicare PIN