Provider Demographics
NPI:1164503900
Name:DUERKSEN, RONALD GARY (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:GARY
Last Name:DUERKSEN
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 1:1055 NORTH 300 WEST
Mailing Address - Street 2:SUITE 416
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3354
Mailing Address - Country:US
Mailing Address - Phone:801-357-7770
Mailing Address - Fax:801-357-7639
Practice Address - Street 1:1055 NORTH 300 WEST
Practice Address - Street 2:SUITE 416
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3354
Practice Address - Country:US
Practice Address - Phone:801-357-7770
Practice Address - Fax:801-357-7639
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1587841205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05263Medicaid
D20472Medicare UPIN