Healthcare Provider Details

I. General information

NPI: 1528003712
Provider Name (Legal Business Name): JODY A. UNDERWOOD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC 948
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST APC 978 A
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-3534
  • Fax: 401-444-3298
Mailing address:
  • Phone: 401-444-4318
  • Fax: 401-444-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD10700
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: