Healthcare Provider Details

I. General information

NPI: 1720190267
Provider Name (Legal Business Name): ALLA MATSIEVSKAYA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 TOLL GATE RD
WARWICK RI
02886-2715
US

IV. Provider business mailing address

430 TOLL GATE RD
WARWICK RI
02886-2715
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-4343
  • Fax: 401-734-9365
Mailing address:
  • Phone: 401-737-4343
  • Fax: 401-734-9365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD09819
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: