Provider Demographics
NPI:1952322802
Name:AMANULLAH, SIRAJ (MD)
Entity Type:Individual
Prefix:
First Name:SIRAJ
Middle Name:
Last Name:AMANULLAH
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 1:125 WHIPPLE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3258
Mailing Address - Country:US
Mailing Address - Phone:401-519-0330
Mailing Address - Fax:
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:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10763208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI01/14/2010OtherNHPRI
RI04/15/2009OtherUNITED HEALTHCARE
MA0170861Medicaid
MA12/28/2008OtherTUFTS HEALTH PLAN
RI02/01/2007OtherBCBS
RISA47759Medicaid
RI939025129OtherRI MEDICARE GROUP NUMBER
RI1952322802OtherNPI
RISA47759Medicaid
RI007056520Medicare ID - Type Unspecified