Healthcare Provider Details

I. General information

NPI: 1730192964
Provider Name (Legal Business Name): RANDY SCOTT KIMMELMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3467 W HILLSBORO BLVD SUITE B
DEERFIELD BEACH FL
33442-9473
US

IV. Provider business mailing address

3467 W HILLSBORO BLVD SUITE B
DEERFIELD BEACH FL
33442-9473
US

V. Phone/Fax

Practice location:
  • Phone: 954-574-0252
  • Fax: 954-429-1759
Mailing address:
  • Phone: 954-574-0252
  • Fax: 954-429-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS7449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: