Healthcare Provider Details

I. General information

NPI: 1194804831
Provider Name (Legal Business Name): BRIAN F PONTARELLI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 SILVER SPRING ST
PROVIDENCE RI
02904
US

IV. Provider business mailing address

250 WAMPANOAG TRAIL SUITE 205 RHODE ISLAND FOOT CARE INC
EAST PROVIDENCE RI
02915
US

V. Phone/Fax

Practice location:
  • Phone: 401-751-2660
  • Fax: 401-751-9990
Mailing address:
  • Phone: 401-431-0283
  • Fax: 401-438-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDPM00294
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: