Provider Demographics
NPI:1548255433
Name:COUTU, RONALD E (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:E
Last Name:COUTU
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 1:830 OAK ST
Mailing Address - Street 2:SUITE 105W
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1168
Mailing Address - Country:US
Mailing Address - Phone:508-586-2264
Mailing Address - Fax:508-897-4779
Practice Address - Street 1:830 OAK ST
Practice Address - Street 2:SUITE 105W
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1168
Practice Address - Country:US
Practice Address - Phone:508-586-2264
Practice Address - Fax:508-897-4779
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30259207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2093343Medicaid
A65929Medicare UPIN
MAM07619Medicare ID - Type Unspecified