Provider Demographics
NPI:1487675377
Name:FEARON, DEIRDRE (MD)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:FEARON
Suffix:
Gender:F
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 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2508
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-854-2504
Practice Address - Fax:401-854-2519
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10068208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7007378Medicaid
RI939025129OtherRI MEDICARE GROUP NUMBER
RI1487675377OtherNPI
RI370015303OtherRAILROAD MEDICARE
RI12/14/2006OtherNHPRI
MA12/29/2008OtherTUFTS HEALTH PLAN
MA3204898Medicaid
MA12/29/2008OtherTUFTS HEALTH PLAN
RI1487675377OtherNPI