Provider Demographics
NPI:1851318737
Name:RONCALLO, RUBEN RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUBEN
Middle Name:RAFAEL
Last Name:RONCALLO
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 1:4500 NORTH MESA
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912
Mailing Address - Country:US
Mailing Address - Phone:915-532-9000
Mailing Address - Fax:915-532-9006
Practice Address - Street 1:4500 NORTH MESA
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912
Practice Address - Country:US
Practice Address - Phone:915-532-9000
Practice Address - Fax:915-532-9006
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154900802OtherTHSTEPS BORDER PEDIATRICS
TX101868104Medicaid
TX101868105OtherCHSCN
TX101868104Medicaid