Provider Demographics
NPI:1164785549
Name:MANTILLA, RONNIE DANIEL (MD)
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:DANIEL
Last Name:MANTILLA
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 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4760 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2328
Practice Address - Country:US
Practice Address - Phone:910-738-9414
Practice Address - Fax:910-738-1012
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-00547207RP1001X
IDM15022207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program