Provider Demographics
NPI:1942200316
Name:WATANABE, RONALD KIYOSHI (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:KIYOSHI
Last Name:WATANABE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:RONALD
Other - Middle Name:K
Other - Last Name:WATANABE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:15 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3718
Mailing Address - Country:US
Mailing Address - Phone:978-475-5252
Mailing Address - Fax:978-475-2226
Practice Address - Street 1:15 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3718
Practice Address - Country:US
Practice Address - Phone:978-475-5252
Practice Address - Fax:978-475-2226
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1552937OtherCOVENTRY
MA402787OtherTUFTS
MAW16025OtherBCBS
610461OtherCOMP BENEFITS
MA54742OtherFALLON
MA153220OtherHARVARD PILGRIM
MA317390Medicaid
MA54742OtherFALLON
MA317390Medicaid
MATX6078Medicare PIN