Provider Demographics
NPI:1548250673
Name:JOANETTE, RONALD ROGER (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:ROGER
Last Name:JOANETTE
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 1:315 OAKGROVE ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1176
Mailing Address - Country:US
Mailing Address - Phone:231-398-9266
Mailing Address - Fax:231-398-9268
Practice Address - Street 1:1293 E. PARKDALE AVENUE
Practice Address - Street 2:SUITE 1200A
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-398-1550
Practice Address - Fax:231-398-1691
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045395207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5193311Medicaid
MIE16002099Medicare PIN
MIA73504Medicare UPIN