Provider Demographics
NPI:1184607079
Name:WISDOM, RONALD (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:WISDOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4628 BARNETT RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9352
Mailing Address - Country:US
Mailing Address - Phone:916-734-0601
Mailing Address - Fax:916-734-7946
Practice Address - Street 1:4501 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2229
Practice Address - Country:US
Practice Address - Phone:916-734-3772
Practice Address - Fax:916-734-7946
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48622207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG47514Medicare UPIN