Provider Demographics
NPI:1083808034
Name:SMITH, RONALD A
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11144 US 50
Mailing Address - Street 2:
Mailing Address - City:DILLSBORO
Mailing Address - State:IN
Mailing Address - Zip Code:47018-8415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11144 US 50
Practice Address - Street 2:
Practice Address - City:DILLSBORO
Practice Address - State:IN
Practice Address - Zip Code:47018-8415
Practice Address - Country:US
Practice Address - Phone:812-432-3217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion