Provider Demographics
NPI:1548363278
Name:PERCIACCANTE, RONALD G (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:G
Last Name:PERCIACCANTE
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 1:513 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4001
Mailing Address - Country:US
Mailing Address - Phone:315-788-2211
Mailing Address - Fax:315-788-0956
Practice Address - Street 1:513 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4001
Practice Address - Country:US
Practice Address - Phone:315-788-2211
Practice Address - Fax:315-788-0956
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0923801208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00601698Medicaid
NY00601698Medicaid
NY34489CMedicare ID - Type Unspecified