Provider Demographics
NPI:1376981910
Name:BADESSA, JOHN (COTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:BADESSA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-7420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 KIMBERLY LN
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-7420
Practice Address - Country:US
Practice Address - Phone:401-489-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00238-G174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIOTA00238-GOtherCOTA