Provider Demographics
NPI:1437131430
Name:VEZERIDIS, MICHAEL P (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:VEZERIDIS
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:PO BOX 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:SUITE 470
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-331-1036
Practice Address - Fax:401-868-2317
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD06270208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006495Medicaid
RI9006495Medicaid
RI007056710Medicare PIN
RI029026462Medicare PIN