Provider Demographics
NPI:1558335075
Name:MISTUR, RONALD J (PHD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:MISTUR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32730 WALKERS ROAD
Mailing Address - Street 2:#I 5
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012
Mailing Address - Country:US
Mailing Address - Phone:440-933-8770
Mailing Address - Fax:440-933-8991
Practice Address - Street 1:32730 WALKERS ROAD
Practice Address - Street 2:#I 5
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012
Practice Address - Country:US
Practice Address - Phone:440-933-8770
Practice Address - Fax:440-933-8991
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1813103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000131040OtherANTHEM
OH000000131040OtherMAGELLAN
OHMICP07761Medicare ID - Type Unspecified