Provider Demographics
NPI:1124225594
Name:STOLK, MORDECAI JEREMIAH (MD)
Entity Type:Individual
Prefix:
First Name:MORDECAI
Middle Name:JEREMIAH
Last Name:STOLK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-3525
Mailing Address - Country:US
Mailing Address - Phone:401-438-5950
Mailing Address - Fax:401-435-6700
Practice Address - Street 1:318 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-3525
Practice Address - Country:US
Practice Address - Phone:401-438-5950
Practice Address - Fax:401-435-6700
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD13046207RN0300X
MA241535207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1124225594OtherRI BLUE CROSS
RI1124225594Medicaid
MA1124225594OtherBLUE CROSS OF MASS
RI1124225594OtherRI BLUE CROSS
MA001238402Medicare PIN