Provider Demographics
NPI:1083702385
Name:HAGGERTY, RONALD D (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:HAGGERTY
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 1:6609 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-5194
Mailing Address - Country:US
Mailing Address - Phone:804-824-9153
Mailing Address - Fax:804-694-3174
Practice Address - Street 1:6609 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5194
Practice Address - Country:US
Practice Address - Phone:804-824-9153
Practice Address - Fax:804-694-3174
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101225016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083702385Medicaid
VAP00377910Medicare PIN
VA1083702385Medicaid
H37048Medicare UPIN