Healthcare Provider Details

I. General information

NPI: 1285898890
Provider Name (Legal Business Name): OTIS UPSON WARREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2008
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

PO BOX 9484
PROVIDENCE RI
02940-9484
US

V. Phone/Fax

Practice location:
  • Phone: 401-519-1604
  • Fax: 401-272-0538
Mailing address:
  • Phone: 401-854-2500
  • Fax: 401-854-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD12935
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA98804
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: