Healthcare Provider Details

I. General information

NPI: 1821034943
Provider Name (Legal Business Name): THOMAS RAYMOND WALEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TOLL GATE RD SUITE 102
WARWICK RI
02886-4440
US

IV. Provider business mailing address

200 TOLL GATE ROAD SUITE 102
WARWICK RI
02886-4458
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-7659
  • Fax: 401-738-6425
Mailing address:
  • Phone: 401-738-7659
  • Fax: 401-738-6425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD05762
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: