Provider Demographics
NPI:1619979804
Name:PANTANO, RONALD J (MD)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:J
Last Name:PANTANO
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 1:100 CENTRAL STREET
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608
Mailing Address - Country:US
Mailing Address - Phone:508-363-3616
Mailing Address - Fax:508-363-0607
Practice Address - Street 1:100 CENTRAL STREET
Practice Address - Street 2:4TH FLOOR
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-363-3616
Practice Address - Fax:508-363-0607
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45076207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAN01850Medicare ID - Type Unspecified
MAD88062Medicare UPIN