Provider Demographics
NPI:1124060397
Name:SERRA, RONALD J (OD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:SERRA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WELLS STREET
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891
Mailing Address - Country:US
Mailing Address - Phone:401-348-2020
Mailing Address - Fax:401-596-9348
Practice Address - Street 1:17 WELLS STREET
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891
Practice Address - Country:US
Practice Address - Phone:401-348-2020
Practice Address - Fax:401-596-9348
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODGT486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9009837Medicaid
RI9009837Medicaid
RI007056426Medicare PIN
RI0186990001Medicare NSC