Healthcare Provider Details

I. General information

NPI: 1215385661
Provider Name (Legal Business Name): BRETON ROUSSEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 WARREN AVE STE 302
EAST PROVIDENCE RI
02914-1432
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-606-4230
  • Fax: 401-606-4261
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD16607
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16607
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: