Provider Demographics
NPI:1093785578
Name:HALL, RONALD DAKER III (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:DAKER
Last Name:HALL
Suffix:III
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 1:919 EAST CENTRAL AVENUE
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:LAFOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-2778
Mailing Address - Country:US
Mailing Address - Phone:423-562-6586
Mailing Address - Fax:423-566-4559
Practice Address - Street 1:919 EAST CENTRAL AVENUE
Practice Address - Street 2:SUITE 101B
Practice Address - City:LAFOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2778
Practice Address - Country:US
Practice Address - Phone:423-562-6586
Practice Address - Fax:423-566-4559
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3165571Medicaid
B59314Medicare UPIN
TN3165571Medicare ID - Type Unspecified