Provider Demographics
NPI:1952455933
Name:RONALD J. FORNELLI OD PC
Entity Type:Organization
Organization Name:RONALD J. FORNELLI OD PC
Other - Org Name:BLUE SPRINGS EYE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNERDOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORNELLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-229-3001
Mailing Address - Street 1:3417 NW MILL DR
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3257
Mailing Address - Country:US
Mailing Address - Phone:816-229-3001
Mailing Address - Fax:816-229-9459
Practice Address - Street 1:3417 NW MILL DR
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3257
Practice Address - Country:US
Practice Address - Phone:816-229-3001
Practice Address - Fax:816-229-9459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02154152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT02154Medicare UPIN
MO0577980001Medicare NSC
MOMA1782Medicare PIN