Provider Demographics
NPI:1235200775
Name:INTELISANO, RONALD GEORGE (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:GEORGE
Last Name:INTELISANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 BLACKWOOD CLEMENTON RD
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-4625
Mailing Address - Country:US
Mailing Address - Phone:856-228-0144
Mailing Address - Fax:856-232-0320
Practice Address - Street 1:1504 BLACKWOOD CLEMENTON RD
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-4625
Practice Address - Country:US
Practice Address - Phone:856-228-0144
Practice Address - Fax:856-232-0320
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB05610900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF76253Medicare UPIN
NJIN759661Medicare ID - Type Unspecified