Healthcare Provider Details

I. General information

NPI: 1649809179
Provider Name (Legal Business Name): RYAN DESROCHERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

15 LASALLE SQUARE
PROVIDENCE RI
02903
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-2695
  • Fax: 401-444-4165
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD21443
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: