Provider Demographics
NPI:1962449900
Name:BURTT, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:BURTT
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 1:208 COLLYER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1560
Mailing Address - Country:US
Mailing Address - Phone:401-793-7191
Mailing Address - Fax:401-793-7200
Practice Address - Street 1:208 COLLYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1560
Practice Address - Country:US
Practice Address - Phone:401-793-7191
Practice Address - Fax:401-793-7200
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54366207RC0000X
RIMD13236207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006434Medicaid
RIC90254Medicare UPIN
RI9006434Medicaid