Provider Demographics
NPI:1063466803
Name:PEARSON, RONALD BRADBURN VINCENT JR (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:BRADBURN VINCENT
Last Name:PEARSON
Suffix:JR
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:HC 71 BOX 119D
Mailing Address - Street 2:
Mailing Address - City:ELLAMORE
Mailing Address - State:WV
Mailing Address - Zip Code:26267-9501
Mailing Address - Country:US
Mailing Address - Phone:304-473-0303
Mailing Address - Fax:
Practice Address - Street 1:100 HOYLMAN DR
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-9321
Practice Address - Country:US
Practice Address - Phone:304-364-1153
Practice Address - Fax:304-364-1154
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20152208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBR5113081OtherMEDICARE PART B GROUP
WV0001417002OtherMEDICAID GROUP
WV5T5100381OtherMEDICARE GROUP
WV7300262000Medicaid
WVBR5113081OtherMEDICARE PART B GROUP