Basic Information
| Provider Information | |||||||||
| NPI: | 1629172317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAN JUAN | ||||||||
| FirstName: | RONALDO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1239 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246600 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 KIRTS BLVD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480844134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246299 | ||||||||
| FaxNumber: | 2484790525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301031888 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208D00000X | 4301031888 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 207RI0011X | 4301031888 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 4362240 | 05 | MI | MEDICAID | 010065414 | 01 | MI | RR MEDICARE | OTHER | 700F374320 | 01 | MI | BCBS OF MI GROUP # | OTHER |