Provider Demographics
NPI:1194720193
Name:COUTU, RONALD BERNARD (OD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:BERNARD
Last Name:COUTU
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:87 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-2730
Practice Address - Country:US
Practice Address - Phone:603-935-5966
Practice Address - Fax:603-935-5968
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0588152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30005460Medicaid
NH30005460Medicaid
RE2342Medicare ID - Type Unspecified