Healthcare Provider Details

I. General information

NPI: 1124350103
Provider Name (Legal Business Name): LAINE WATANABE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WOODLAND DR
COVENTRY RI
02816-6716
US

IV. Provider business mailing address

PO BOX 7411009
CHICAGO IL
60674-3009
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 872-231-3162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD17197
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: