Healthcare Provider Details

I. General information

NPI: 1386626174
Provider Name (Legal Business Name): DENIS E MOONAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 SMITH ST SUITE N
NORTH PROVIDENCE RI
02911-2947
US

IV. Provider business mailing address

1515 SMITH ST SUITE N
NORTH PROVIDENCE RI
02911-2947
US

V. Phone/Fax

Practice location:
  • Phone: 401-353-0555
  • Fax: 401-353-7079
Mailing address:
  • Phone: 401-353-0555
  • Fax: 401-353-7079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD05654
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberMD05654
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD05654
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: