Healthcare Provider Details

I. General information

NPI: 1366133555
Provider Name (Legal Business Name): ANDREA DEPOUTOT OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 TOLL GATE RD
WARWICK RI
02886-2716
US

IV. Provider business mailing address

566 TOLL GATE RD
WARWICK RI
02886-2716
US

V. Phone/Fax

Practice location:
  • Phone: 860-331-0464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3297
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTG00761
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: