Provider Demographics
NPI:1922064534
Name:MACHATA, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:MACHATA
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 1:320 PHILLIPS ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5166
Mailing Address - Country:US
Mailing Address - Phone:404-294-9949
Mailing Address - Fax:888-898-5898
Practice Address - Street 1:320 PHILLIPS STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5149
Practice Address - Country:US
Practice Address - Phone:401-294-9949
Practice Address - Fax:888-898-5898
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7004417Medicaid
B97785Medicare UPIN
RI7004417Medicaid