Provider Demographics
NPI:1821275355
Name:RONALD B KILLIAN DPM LLC
Entity Type:Organization
Organization Name:RONALD B KILLIAN DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:928-854-4307
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-0604
Mailing Address - Country:US
Mailing Address - Phone:928-854-4307
Mailing Address - Fax:928-854-4339
Practice Address - Street 1:1731 MESQUITE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5653
Practice Address - Country:US
Practice Address - Phone:928-854-4307
Practice Address - Fax:928-854-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0554213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ305439Medicaid
AZDO8411OtherRAILROAD MEDICARE
AZDO8411OtherRAILROAD MEDICARE
AZ305439Medicaid
AZU85546Medicare UPIN