=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174510945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRAKASH B. CHOUGULE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2005
-----------------------------------------------------
Last Update Date | 12/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 TOLL GATE RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-2715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-732-2300
-----------------------------------------------------
Fax | 401-738-3450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 COLONIAL BLVD ATTN: PAYER CONTRACTING & RELATIONS DEPT.
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-7342
-----------------------------------------------------
Fax | 239-931-7385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | MD06662
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------