Provider Demographics
NPI:1629180757
Name:MOULE, BERNARD A (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:A
Last Name:MOULE
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 1:281 WICKFORD POINT RD
Mailing Address - Street 2:
Mailing Address - City:N KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 VETERANS MEMORIAL PKWY
Practice Address - Street 2:BUILDING 14
Practice Address - City:E PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5300
Practice Address - Country:US
Practice Address - Phone:401-435-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05366208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020355Medicaid
RI20355OtherBLUE SHIELD
RI007060747Medicare PIN
RI9020355Medicaid
RI20355OtherBLUE SHIELD