Provider Demographics
NPI:1730271701
Name:MEDLOCK, RONALD DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DAVID
Last Name:MEDLOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 360064
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35236-0064
Mailing Address - Country:US
Mailing Address - Phone:205-560-0477
Mailing Address - Fax:205-560-0477
Practice Address - Street 1:832 PRINCETON AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1320
Practice Address - Country:US
Practice Address - Phone:205-206-8320
Practice Address - Fax:205-206-8368
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS587TA195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT87426OtherVIVA HEALTHCARE
AL3534OtherSENIORS FIRST
AL00002584Medicaid
AL2210512OtherUNITED HEALTHCARE
AL25842OtherBLUE CROSS
ALT87426OtherHEALTHSPRINGS
AL990003808OtherMEDICARE RAILROAD
AL2210512OtherUNITED HEALTHCARE
AL25842Medicare ID - Type Unspecified