Healthcare Provider Details

I. General information

NPI: 1447260633
Provider Name (Legal Business Name): RONALD A VAN TUYL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 RIVERSTONE DR
CANTON GA
30114
US

IV. Provider business mailing address

215 RIVERSTONE DR
CANTON GA
30114
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-6600
  • Fax: 770-345-6611
Mailing address:
  • Phone: 770-345-6600
  • Fax: 770-345-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number030684
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number030684
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number030684
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: