Healthcare Provider Details

I. General information

NPI: 1245971050
Provider Name (Legal Business Name): DR. NICHOLAS COCCOLUTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
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:
Mailing address:
  • Phone: 401-606-4286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number293004
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberCLP05854
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: