Healthcare Provider Details

I. General information

NPI: 1750357596
Provider Name (Legal Business Name): GEORGE GIFFAULT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WELLS ST
WESTERLY RI
02891-2922
US

IV. Provider business mailing address

365 MONTAUK AVE ROOM 4.512
NEW LONDON CT
06320-4700
US

V. Phone/Fax

Practice location:
  • Phone: 800-933-5960
  • Fax:
Mailing address:
  • Phone: 860-442-0711
  • Fax: 860-444-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO00542
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number040038
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number040038
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDO00542
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: