Provider Demographics
NPI:1780687400
Name:POTENZA, ANTHONY R (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:R
Last Name:POTENZA
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 1:38 HAMLET AVE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4423
Mailing Address - Country:US
Mailing Address - Phone:401-762-0020
Mailing Address - Fax:
Practice Address - Street 1:38 HAMLET AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4423
Practice Address - Country:US
Practice Address - Phone:401-762-0020
Practice Address - Fax:401-762-1819
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD044452085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3122409Medicaid
MA37750OtherMA LICENSE
RIMD04445OtherRI LICENSE
RI7000164Medicaid
RI007002821Medicare ID - Type Unspecified
MA37750OtherMA LICENSE
RIMD04445OtherRI LICENSE