Healthcare Provider Details

I. General information

NPI: 1649732702
Provider Name (Legal Business Name): ABHAY MATHUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

455 TOLL GATE RD PRC AND CREDENTIALING
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-729-2800
  • Fax: 401-729-2877
Mailing address:
  • Phone: 401-273-0641
  • Fax: 401-273-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD20562
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: