Provider Demographics
NPI:1649496001
Name:DOCTOR, RONALD M (PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:M
Last Name:DOCTOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18208 KINGSPORT DR
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-5636
Mailing Address - Country:US
Mailing Address - Phone:310-230-9804
Mailing Address - Fax:
Practice Address - Street 1:18208 KINGSPORT DR
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5636
Practice Address - Country:US
Practice Address - Phone:310-230-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL3474103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical