Provider Demographics
NPI:1063405264
Name:DISIMONE, RONALD ENRICO (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ENRICO
Last Name:DISIMONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE
Practice Address - Street 2:SUITE 101-103
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2647
Practice Address - Country:US
Practice Address - Phone:570-321-2020
Practice Address - Fax:570-320-7576
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029691-E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010866270001Medicaid
PA489816OtherHIGHMARK BLUE SHIELD
PA489816OtherHIGHMARK BLUE SHIELD
PAP00694691Medicare PIN
PAP00694691Medicare PIN
PA489816Medicare PIN