Provider Demographics
NPI:1205826997
Name:DE CESARE, PAUL A (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:DE CESARE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909
Mailing Address - Country:US
Mailing Address - Phone:401-331-4475
Mailing Address - Fax:401-273-5742
Practice Address - Street 1:354 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909
Practice Address - Country:US
Practice Address - Phone:401-331-4475
Practice Address - Fax:401-273-5742
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00322152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPC03311Medicaid
0631570001Medicare NSC
RIPC03311Medicaid
RIT79262Medicare UPIN
T79292Medicare UPIN
419007971Medicare PIN