Provider Demographics
NPI:1407818966
Name:DUFRESNE, RAYMOND G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:G
Last Name:DUFRESNE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:APC-10
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-7024
Mailing Address - Fax:401-444-7135
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:APC-10
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-7024
Practice Address - Fax:401-444-7135
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07571207ND0101X
RIMD7571207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006557Medicaid
RI9006557Medicaid