Provider Demographics
NPI:1205813565
Name:KILLIAN, RONALD BERNARD (DPM)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:BERNARD
Last Name:KILLIAN
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 1:25 RIVIERA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5694
Mailing Address - Country:US
Mailing Address - Phone:928-505-5555
Mailing Address - Fax:928-505-2877
Practice Address - Street 1:25 RIVIERA BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5694
Practice Address - Country:US
Practice Address - Phone:928-505-5555
Practice Address - Fax:928-505-2877
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0554213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ305439Medicaid
U85546Medicare UPIN
AZZ135838Medicare PIN