Healthcare Provider Details

I. General information

NPI: 1922063577
Provider Name (Legal Business Name): LEON RONEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9815
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9815
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-6999
  • Fax: 304-757-3252
Mailing address:
  • Phone: 304-757-6999
  • Fax: 304-757-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19878
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19878
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: