Provider Demographics
NPI:1407830334
Name:ROESLER, THOMAS ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALLEN
Last Name:ROESLER
Suffix:
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 1:593 EDDY ST
Mailing Address - Street 2:APC 978
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-7865
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:PHYSICIAN'S OFFICE BLDG., # 122
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4515
Practice Address - Fax:401-444-7018
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD093042084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006470Medicaid
007007264Medicare ID - Type Unspecified
RI7006470Medicaid