Healthcare Provider Details

I. General information

NPI: 1013413012
Provider Name (Legal Business Name): JOSHUA KENNETH POTVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 01/22/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-606-4286
  • Fax: 401-444-5090
Mailing address:
  • Phone: 401-606-4286
  • Fax: 401-444-5090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD19193
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: