Provider Demographics
NPI:1467487561
Name:ERVIN, RONDIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:RONDIE
Middle Name:L
Last Name:ERVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 DENNARD RD NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1181
Mailing Address - Country:US
Mailing Address - Phone:678-413-0552
Mailing Address - Fax:678-729-0073
Practice Address - Street 1:1775 ACCESS RD
Practice Address - Street 2:STE. B
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1987
Practice Address - Country:US
Practice Address - Phone:770-255-1063
Practice Address - Fax:678-729-0073
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022405174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00433298DMedicaid
GA200629861OtherTAX ID
GAB70701Medicare UPIN