Provider Demographics
NPI:1699713396
Name:NIKLASON, RANDY F (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:F
Last Name:NIKLASON
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 1:3916 STATE ST
Mailing Address - Street 2:#300
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-5602
Mailing Address - Country:US
Mailing Address - Phone:805-563-3011
Mailing Address - Fax:805-564-5087
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-242-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-6350207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03199801Medicaid
E79261Medicare UPIN
HIH52776Medicare PIN