Provider Demographics
NPI:1205817392
Name:FOREMAN, RONALD R (OD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:R
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 SW MAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5791
Mailing Address - Country:US
Mailing Address - Phone:386-752-1722
Mailing Address - Fax:386-755-1858
Practice Address - Street 1:763 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5791
Practice Address - Country:US
Practice Address - Phone:386-752-1722
Practice Address - Fax:386-755-1858
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084869700Medicaid
FL19135AMedicare ID - Type Unspecified
T85192Medicare UPIN