Provider Demographics
NPI:1326174301
Name:PALM, RONALD MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:MATTHEW
Last Name:PALM
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 1:550 DIETZ AVE NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4615
Mailing Address - Country:US
Mailing Address - Phone:503-393-0540
Mailing Address - Fax:
Practice Address - Street 1:550 DIETZ AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4615
Practice Address - Country:US
Practice Address - Phone:503-393-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232446Medicaid
OR133414Medicare ID - Type Unspecified
ORG99921Medicare UPIN