Healthcare Provider Details

I. General information

NPI: 1285630947
Provider Name (Legal Business Name): SUSAN L PAKULA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COMMERCE ST PEDIATRICS
LINCOLN RI
02865-1168
US

IV. Provider business mailing address

1 COMMERCE ST PEDIATRICS
LINCOLN RI
02865-1168
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8484
  • Fax: 401-793-8481
Mailing address:
  • Phone: 401-793-8484
  • Fax: 401-793-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD05525
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: