Provider Demographics
NPI:1376905455
Name:ELMALLAH, RANDA DIANA (MD)
Entity type:Individual
Prefix:MS
First Name:RANDA
Middle Name:DIANA
Last Name:ELMALLAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RANDA
Other - Middle Name:DIANA KAMAL
Other - Last Name:ELMALLAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:881 E EMERALD TER
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME168335207X00000X
MA286499207X00000X
390200000X
MO2022029948207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200113384Medicaid