Basic Information
| Provider Information | |||||||||
| NPI: | 1730271701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDLOCK | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 360064 | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352360064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2055600477 | ||||||||
| FaxNumber: | 2055600477 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 PRINCETON AVE SW | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052068320 | ||||||||
| FaxNumber: | 2052068368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/17/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S587TA195 | AL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | T87426 | 01 | AL | VIVA HEALTHCARE | OTHER | 3534 | 01 | AL | SENIORS FIRST | OTHER | 00002584 | 05 | AL | MEDICAID | 2210512 | 01 | AL | UNITED HEALTHCARE | OTHER | 25842 | 01 | AL | BLUE CROSS | OTHER | T87426 | 01 | AL | HEALTHSPRINGS | OTHER | 990003808 | 01 | AL | MEDICARE RAILROAD | OTHER |