Provider Demographics
NPI:1134111404
Name:ISACKSON, RONALD D (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:ISACKSON
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 1:109 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3949
Mailing Address - Country:US
Mailing Address - Phone:701-483-2973
Mailing Address - Fax:701-483-2983
Practice Address - Street 1:109 7TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3949
Practice Address - Country:US
Practice Address - Phone:701-483-2973
Practice Address - Fax:701-483-2983
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13286Medicaid
NDC64228Medicare UPIN
NDN711298Medicare ID - Type Unspecified