Healthcare Provider Details

I. General information

NPI: 1124225594
Provider Name (Legal Business Name): MORDECAI JEREMIAH STOLK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WATERMAN AVE
EAST PROVIDENCE RI
02914-3525
US

IV. Provider business mailing address

318 WATERMAN AVE
EAST PROVIDENCE RI
02914-3525
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-5950
  • Fax: 401-435-6700
Mailing address:
  • Phone: 401-438-5950
  • Fax: 401-435-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD13046
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number241535
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: