Provider Demographics
NPI:1427042159
Name:MANICOM, RONALD EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:EDWARD
Last Name:MANICOM
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 1:711 W 38TH ST
Mailing Address - Street 2:D-4
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1121
Mailing Address - Country:US
Mailing Address - Phone:512-454-9627
Mailing Address - Fax:512-454-6310
Practice Address - Street 1:711 W 38TH ST
Practice Address - Street 2:D-4
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1121
Practice Address - Country:US
Practice Address - Phone:512-454-9627
Practice Address - Fax:512-454-6310
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-01-20
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
TXC9055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180051801Medicaid
TXC18737Medicare PIN
TX8F0996Medicare PIN