Provider Demographics
NPI:1790794238
Name:RONNA, THERESA G (DPM)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:G
Last Name:RONNA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:G
Other - Last Name:RONNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:784 FRANKLIN AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-1306
Mailing Address - Country:US
Mailing Address - Phone:201-560-0711
Mailing Address - Fax:201-560-0712
Practice Address - Street 1:784 FRANKLIN AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:FRANKLIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07417-1306
Practice Address - Country:US
Practice Address - Phone:201-560-0711
Practice Address - Fax:201-560-0712
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00243900213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0057711Medicaid
NJU94600Medicare UPIN
NJ0057711Medicaid