Provider Demographics
NPI:1164785549
Name:MANTILLA, RONNIE DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:DANIEL
Last Name:MANTILLA
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-3555
Mailing Address - Fax:208-625-3556
Practice Address - Street 1:700 W IRONWOOD DR STE 378
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-3555
Practice Address - Fax:208-625-3556
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM15022207RP1001X
WAMD60859642207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program