Healthcare Provider Details

I. General information

NPI: 1366429102
Provider Name (Legal Business Name): OPHTHALMOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E MANNING ST
PROVIDENCE RI
02906-5109
US

IV. Provider business mailing address

150 E MANNING ST
PROVIDENCE RI
02906-5109
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-2020
  • Fax: 401-421-5979
Mailing address:
  • Phone: 401-272-2020
  • Fax: 401-421-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTA00377
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD05032
License Number StateRI

VIII. Authorized Official

Name: GAIL P DUELL
Title or Position: ACCOUNTS MANAGER
Credential: CPC, CEMC
Phone: 401-272-2010