Provider Demographics
NPI:1871554261
Name:ANNICELLI, RONDA JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:RONDA
Middle Name:JEAN
Last Name:ANNICELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RONDA
Other - Middle Name:JEAN
Other - Last Name:LEADHOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1263 ERDMAN CT
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-7477
Mailing Address - Country:US
Mailing Address - Phone:508-310-3412
Mailing Address - Fax:
Practice Address - Street 1:1263 ERDMAN CT
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-7477
Practice Address - Country:US
Practice Address - Phone:508-310-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL 6487207Q00000X
NV10250207Q00000X
CA132974207Q00000X
FLME 81170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H71003Medicare UPIN