Provider Demographics
NPI:1295728053
Name:MCCORD, RONALD EUGENE (OD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:EUGENE
Last Name:MCCORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1464
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34958-1464
Mailing Address - Country:US
Mailing Address - Phone:772-335-2209
Mailing Address - Fax:
Practice Address - Street 1:1701 SE TIFFANY AVE
Practice Address - Street 2:STE 105
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7576
Practice Address - Country:US
Practice Address - Phone:772-335-2209
Practice Address - Fax:772-337-9177
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 002078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078913500Medicaid
U10974Medicare UPIN
FL0664440001Medicare NSC
FL20236Medicare PIN