Provider Demographics
NPI:1518967470
Name:ALLEN, RONALD L (MD)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:L
Last Name:ALLEN
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 1:4060 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3121
Mailing Address - Country:US
Mailing Address - Phone:262-752-2020
Mailing Address - Fax:
Practice Address - Street 1:4060 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3121
Practice Address - Country:US
Practice Address - Phone:262-752-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26907-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1014080001OtherADMINASTAR-DMERC
WI31447000Medicaid
WI180011992Medicare ID - Type UnspecifiedRAILROAD
WI1014080001OtherADMINASTAR-DMERC
WI31447000Medicaid