Provider Demographics
NPI:1114038445
Name:KWETKOWSKI, BRIAN GEORGE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GEORGE
Last Name:KWETKOWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-738-7015
Mailing Address - Fax:401-295-1230
Practice Address - Street 1:320 PHILLIPS ST STE 201
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5149
Practice Address - Country:US
Practice Address - Phone:401-295-3120
Practice Address - Fax:401-295-1230
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBK42026Medicaid
G99572Medicare UPIN
RI089023993Medicare ID - Type Unspecified