Provider Demographics
NPI:1275510356
Name:BOOGAARD, RONALD G (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:G
Last Name:BOOGAARD
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 1:130 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-8915
Mailing Address - Country:US
Mailing Address - Phone:717-274-5902
Mailing Address - Fax:
Practice Address - Street 1:130 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-8915
Practice Address - Country:US
Practice Address - Phone:717-274-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031413E174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018856010004Medicaid
PA0018856010004Medicaid
PA090672Medicare PIN