Provider Demographics
NPI:1194793414
Name:MARTINO, RONALD A (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:A
Last Name:MARTINO
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:PO BOX 73410
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3410
Mailing Address - Country:US
Mailing Address - Phone:800-478-4091
Mailing Address - Fax:907-770-2341
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:STE 220
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5942
Practice Address - Country:US
Practice Address - Phone:907-452-1739
Practice Address - Fax:907-452-2384
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK16952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1695Medicaid
AKMD1695Medicaid
AK026WCHCVBMedicare ID - Type Unspecified