Provider Demographics
NPI:1508821364
Name:PUTHAWALA, MOHAMEDYAKUB A (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMEDYAKUB
Middle Name:A
Last Name:PUTHAWALA
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:DEPT OF RADIATION ONCOLOGY
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-8311
Mailing Address - Fax:401-444-5335
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:DEPT OF RADIATION ONCOLOGY
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-8311
Practice Address - Fax:401-444-5335
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD078182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2400030OtherUNITED HEALTHCARE
RI7002082Medicaid
RI4804-8OtherBLUE CROSS BLUE SHIELD
RIE28471Medicare UPIN
RI007006673Medicare ID - Type Unspecified
RI2400030OtherUNITED HEALTHCARE