Provider Demographics
NPI:1952310476
Name:PANETTA, RANDOLPH ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:ALEXANDER
Last Name:PANETTA
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 1:399 9TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5820
Mailing Address - Country:US
Mailing Address - Phone:239-624-4200
Mailing Address - Fax:239-624-4241
Practice Address - Street 1:399 9TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5820
Practice Address - Country:US
Practice Address - Phone:239-624-4200
Practice Address - Fax:239-624-4241
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044184207RC0000X
FLME139310207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB9C2FOtherBCBS
CT044184OtherLICENSE
FL102508000Medicaid