Healthcare Provider Details

I. General information

NPI: 1841204971
Provider Name (Legal Business Name): RANDOLPH B PEDDICORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SE INDIAN ST
STUART FL
34997-5688
US

IV. Provider business mailing address

1201 SE INDIAN ST
STUART FL
34997-5688
US

V. Phone/Fax

Practice location:
  • Phone: 772-403-4500
  • Fax: 772-403-4500
Mailing address:
  • Phone: 772-403-4500
  • Fax: 772-403-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS6696
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: