Healthcare Provider Details

I. General information

NPI: 1679054043
Provider Name (Legal Business Name): CARLOS G WAMBIER MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 VILLAGE SQUARE DR STE 201
SOUTH KINGSTOWN RI
02879-2292
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-1120
  • Fax:
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD17358
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: