Provider Demographics
NPI:1669430633
Name:WHARTON, RONALD (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:WHARTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2916
Mailing Address - Country:US
Mailing Address - Phone:718-283-7147
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183142207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01416182Medicaid
62K821Medicare ID - Type Unspecified
NY01416182Medicaid