Healthcare Provider Details

I. General information

NPI: 1215911367
Provider Name (Legal Business Name): DONALD R COUSTAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DUDLEY ST
PROVIDENCE RI
02905-2401
US

IV. Provider business mailing address

101 DUDLEY ST
PROVIDENCE RI
02905-2401
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-1122
  • Fax: 401-453-7599
Mailing address:
  • Phone: 401-274-1122
  • Fax: 401-453-7599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number6028
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6028
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: