1306809603 NPI number — JONATHAN G SABOURIN DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306809603 NPI number — JONATHAN G SABOURIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SABOURIN
Provider First Name:
JONATHAN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306809603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 AQUIDNECK AVE STE 15
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02842-7280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-849-2157
Provider Business Mailing Address Fax Number:
401-848-8441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 AQUIDNECK AVE STE 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02842-7280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-849-2157
Provider Business Practice Location Address Fax Number:
401-848-8441
Provider Enumeration Date:
04/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  DPM00316 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 2210 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: DPM00316 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 212867 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 7056541 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 411583 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com