Provider Demographics
NPI:1962455626
Name:TRUDEL, RONALD RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:RAYMOND
Last Name:TRUDEL
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 1:3465 E MAGIC HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-7243
Mailing Address - Country:US
Mailing Address - Phone:801-891-9313
Mailing Address - Fax:801-944-2472
Practice Address - Street 1:3465 MAGIC HILLS CIRCLE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-0000
Practice Address - Country:US
Practice Address - Phone:801-891-9313
Practice Address - Fax:801-944-2472
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4866189-1205207RG0300X, 208M00000X, 207R00000X
UT48661891205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT48661891202001OtherBCBS
UT2203454002OtherCIGNA
UT2203454002OtherCIGNA
UT005589901Medicare ID - Type UnspecifiedMEDICARE