Provider Demographics
NPI:1124072822
Name:HOMER, RONALD A (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:A
Last Name:HOMER
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 1:1370 MONTREAL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:404-446-4600
Mailing Address - Fax:404-446-4601
Practice Address - Street 1:1370 MONTREAL RD
Practice Address - Street 2:STE 180
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:404-446-4600
Practice Address - Fax:404-446-4601
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050105208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000940266KMedicaid
GA000940266KMedicaid