Basic Information
| Provider Information | |||||||||
| NPI: | 1669413084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNOBLOCK | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613833820 | ||||||||
| FaxNumber: | 8553692450 | ||||||||
| Practice Location | |||||||||
| Address1: | 7455 W WASHINGTON AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775625227 | ||||||||
| FaxNumber: | 7029389954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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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 | 207ZF0201X | 10511 | NV | N | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | 207ZH0000X | 10511 | NV | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | 10511 | NV | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 100511109 | 05 | NV | MEDICAID |