Healthcare Provider Details

I. General information

NPI: 1275667248
Provider Name (Legal Business Name): CASIMIRA CARLOS STA INES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 ATWOOD AVE SUITE 100
JOHNSTON RI
02919-3289
US

IV. Provider business mailing address

17 MICHELLE CIR
WARWICK RI
02886-8592
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-9400
  • Fax:
Mailing address:
  • Phone: 401-884-3942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD05965
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: