Provider Demographics
NPI:1174500722
Name:SMALL, RONALD J (DPM)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:SMALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-1027
Mailing Address - Country:US
Mailing Address - Phone:215-924-2521
Mailing Address - Fax:215-924-2367
Practice Address - Street 1:104 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1027
Practice Address - Country:US
Practice Address - Phone:215-924-2521
Practice Address - Fax:215-924-2367
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-26
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003322L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011782190007Medicaid
PA0011782190007Medicaid
PA426838Medicare PIN
PA480034317Medicare PIN