Provider Demographics
NPI:1689850620
Name:DELRIE, RONALD DWAYNE JR (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:DWAYNE
Last Name:DELRIE
Suffix:JR
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 1:1501 ASTON AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2734
Mailing Address - Country:US
Mailing Address - Phone:601-249-5510
Mailing Address - Fax:
Practice Address - Street 1:1501 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2734
Practice Address - Country:US
Practice Address - Phone:601-249-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-20
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA205787207RH0003X
MS24455207RH0003X
GA002147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP01123394OtherRAILROAD MEDICARE
MS04554501Medicaid
LA2310178Medicaid
LA248759YJS0Medicare PIN
MS04554501Medicaid