Healthcare Provider Details

I. General information

NPI: 1952322802
Provider Name (Legal Business Name): SIRAJ AMANULLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 11/29/2023
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST CLAVERICK 2
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

125 WHIPPLE ST STE 3
PROVIDENCE RI
02908-3258
US

V. Phone/Fax

Practice location:
  • Phone: 401-854-2504
  • Fax: 401-854-2519
Mailing address:
  • Phone: 401-519-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD10763
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD10763
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: