Provider Demographics
NPI:1790881696
Name:MEDWICK, RONALD L (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:MEDWICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 VAUXHALL STREET
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385
Mailing Address - Country:US
Mailing Address - Phone:860-442-1466
Mailing Address - Fax:860-442-3191
Practice Address - Street 1:567 VAUXHALL STREET
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-442-1466
Practice Address - Fax:860-442-3191
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004080941Medicaid
410000241Medicare ID - Type Unspecified
CT004080941Medicaid
CT1013790001Medicare NSC