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General NPI Number Information
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NPI Number | 1255302360
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Entity Type | Individual
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Provider Name | RANDALL L BRADDOM M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/27/2006
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 1093 GOLDEN GROVE DR
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City | THE VILLAGES
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State | FL
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Zip | 32162-4023
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Country | US
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Telephone | 908-601-7036
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Fax | 352-561-4512
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Provider Business Mailing Address
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Address Line | 1093 GOLDEN GROVE DR
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City | THE VILLAGES
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State | FL
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Zip | 32162-4023
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Country | US
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Telephone | 908-601-7036
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Fax | 352-561-4512
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 25MA02637400
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License Number State | NJ
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