Provider Demographics
NPI:1013121235
Name:WISDOM, RONALD K (DC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:K
Last Name:WISDOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-4467
Mailing Address - Country:US
Mailing Address - Phone:802-229-4922
Mailing Address - Fax:802-223-1214
Practice Address - Street 1:155 ELM ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-4467
Practice Address - Country:US
Practice Address - Phone:802-229-4922
Practice Address - Fax:802-223-1214
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-0001006111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN1635Medicare UPIN