Provider Demographics
NPI:1073518288
Name:FEJERAN, RONALD JC (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:JC
Last Name:FEJERAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37824-0959
Mailing Address - Country:US
Mailing Address - Phone:423-626-1931
Mailing Address - Fax:
Practice Address - Street 1:1442 N BROAD ST
Practice Address - Street 2:SUITE 7
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-4361
Practice Address - Country:US
Practice Address - Phone:423-626-1931
Practice Address - Fax:423-626-1948
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN999208000000X
TND0999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3303563Medicaid
TN1506800Medicaid
33035631Medicare PIN