Provider Demographics
NPI:1568509610
Name:MANFRE, RONALDO (WIG PROVIDER)
Entity Type:Individual
Prefix:MR
First Name:RONALDO
Middle Name:
Last Name:MANFRE
Suffix:
Gender:M
Credentials:WIG PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-5003
Mailing Address - Country:US
Mailing Address - Phone:339-222-0555
Mailing Address - Fax:781-376-4363
Practice Address - Street 1:231 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-5003
Practice Address - Country:US
Practice Address - Phone:781-721-2055
Practice Address - Fax:781-376-4363
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57429 AND OR 1091276174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1568509610Medicare NSC