Healthcare Provider Details

I. General information

NPI: 1770555138
Provider Name (Legal Business Name): RONALD V LACRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

PO BOX 9135
BROOKLINE MA
02446-9135
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2793
  • Fax:
Mailing address:
  • Phone: 800-927-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number57896
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number57896
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number57896
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: