Healthcare Provider Details

I. General information

NPI: 1962409128
Provider Name (Legal Business Name): JOHN CONCANNON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/25/2006

III. Provider practice location address

1145 RESERVOIR AVE SUITE 124
CRANSTON RI
02920-6055
US

IV. Provider business mailing address

1145 RESERVOIR AVE SUITE 124
CRANSTON RI
02920-6055
US

V. Phone/Fax

Practice location:
  • Phone: 401-943-7337
  • Fax: 401-942-1509
Mailing address:
  • Phone: 401-943-7337
  • Fax: 401-942-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO-00357
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: