Provider Demographics
NPI:1275614539
Name:DICK, RONALD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:DICK
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 1:47 NEW SCOTLAND AVE
Mailing Address - Street 2:MC-88
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVE
Practice Address - Street 2:MC-88
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025625208000000X
NY60-273120208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8113268Medicaid
7246OtherINTERNAL ID-MOTOR VEHICLE ID
AB39069Medicare ID - Type Unspecified
WA8113268Medicaid