Provider Demographics
NPI:1376829135
Name:BACKUS, RONALD ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:ARTHUR
Last Name:BACKUS
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 1:4185 W LAKE ELWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:WI
Mailing Address - Zip Code:54121-9158
Mailing Address - Country:US
Mailing Address - Phone:715-696-6416
Mailing Address - Fax:
Practice Address - Street 1:4185 W LAKE ELWOOD RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-9158
Practice Address - Country:US
Practice Address - Phone:715-696-6416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice