Provider Demographics
NPI:1851390397
Name:ESCUDERO, RONALD J (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:ESCUDERO
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 1:4100 WOLCOTT AVE NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4571
Mailing Address - Country:US
Mailing Address - Phone:505-855-5500
Mailing Address - Fax:505-855-5501
Practice Address - Street 1:4100 WOLCOTT AVE NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4571
Practice Address - Country:US
Practice Address - Phone:505-855-5500
Practice Address - Fax:505-855-5501
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-196174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42085Medicaid
NM42085Medicaid