Provider Demographics
NPI:1629172317
Name:SAN JUAN, RONALDO (MD)
Entity Type:Individual
Prefix:
First Name:RONALDO
Middle Name:
Last Name:SAN JUAN
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:500 KIRTS BLVD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4134
Practice Address - Country:US
Practice Address - Phone:248-824-6299
Practice Address - Fax:248-479-0525
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010318882085R0202X, 208D00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4362240Medicaid
MI010065414OtherRR MEDICARE
MI700F374320OtherBCBS OF MI GROUP #
MI4362240Medicaid
MI700F374320OtherBCBS OF MI GROUP #