Healthcare Provider Details

I. General information

NPI: 1972726495
Provider Name (Legal Business Name): MARK MADDOX O'BRIEN M.D. , M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HARRINGTON RD
CRANSTON RI
02920-3080
US

IV. Provider business mailing address

6 HARRINGTON RD
CRANSTON RI
02920-3080
US

V. Phone/Fax

Practice location:
  • Phone: 401-462-2760
  • Fax: 401-462-2757
Mailing address:
  • Phone: 401-462-2760
  • Fax: 401-462-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberMD05818
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: