Basic Information
| Provider Information | |||||||||
| NPI: | 1083652812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RONCO | ||||||||
| FirstName: | DOMENICK | ||||||||
| MiddleName: | NICHOLAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 FOREST HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIFFLINBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178447066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709661004 | ||||||||
| FaxNumber: | 5709663736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 12/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS004260L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0006755230001 | 05 | PA | MEDICAID |