Provider Demographics
NPI:1801897897
Name:WILLENBORG, RONALD KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:KEITH
Last Name:WILLENBORG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:543 VALLEY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1844
Mailing Address - Country:US
Mailing Address - Phone:973-746-6466
Mailing Address - Fax:973-746-0312
Practice Address - Street 1:543 VALLEY RD STE 4
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1844
Practice Address - Country:US
Practice Address - Phone:973-746-6466
Practice Address - Fax:973-746-0312
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03592100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP3601332OtherOXFORD HEALTH
NJ3213803Medicaid
NJ0004574647OtherAETNA
NJ001130735OtherUNITED HEALTHCARE
NY31D08OtherEMPIRE BLUE SHIELD
NJOK0464OtherHEALTH NET
NJ8971366OtherCIGNA
NJNJ3106OtherFIRST HEALTH
110009806OtherRAILROAD MEDICARE
NJJ2407OtherHORIZON BLUE CROSS/SHIELD
110009806OtherRAILROAD MEDICARE
NJJ2407OtherHORIZON BLUE CROSS/SHIELD