Provider Demographics
NPI:1306369244
Name:ROTELLA, JOSHUA EDWARD
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:EDWARD
Last Name:ROTELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-3405
Mailing Address - Country:US
Mailing Address - Phone:401-952-3771
Mailing Address - Fax:
Practice Address - Street 1:25 SHATTUCK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6027
Practice Address - Country:US
Practice Address - Phone:401-952-3771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1306369244207P00000X
332B00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid
RI$$$$$$$$$Medicaid