Provider Demographics
NPI:1386626174
Name:MOONAN, DENIS E JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DENIS
Middle Name:E
Last Name:MOONAN
Suffix:JR
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 1:1515 SMITH ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-2947
Mailing Address - Country:US
Mailing Address - Phone:401-353-0555
Mailing Address - Fax:401-353-7079
Practice Address - Street 1:1515 SMITH ST
Practice Address - Street 2:SUITE N
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-2947
Practice Address - Country:US
Practice Address - Phone:401-353-0555
Practice Address - Fax:401-353-7079
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05654207RG0300X, 207RA0401X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002408Medicaid
RI24088OtherBLUE CROSS BLUE SHIELD
RIC03521Medicare UPIN
RI019002408Medicare PIN