Healthcare Provider Details

I. General information

NPI: 1306809603
Provider Name (Legal Business Name): JONATHAN G SABOURIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 AQUIDNECK AVE STE 15
MIDDLETOWN RI
02842-7280
US

IV. Provider business mailing address

850 AQUIDNECK AVE STE 15
MIDDLETOWN RI
02842-7280
US

V. Phone/Fax

Practice location:
  • Phone: 401-849-2157
  • Fax: 401-848-8441
Mailing address:
  • Phone: 401-849-2157
  • Fax: 401-848-8441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDPM00316
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2210
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM00316
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: