Provider Demographics
NPI:1972726495
Name:O'BRIEN, MARK MADDOX (MD , MPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MADDOX
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD , MPH
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6 HARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-3080
Mailing Address - Country:US
Mailing Address - Phone:401-462-2760
Mailing Address - Fax:401-462-2757
Practice Address - Street 1:6 HARRINGTON RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-3080
Practice Address - Country:US
Practice Address - Phone:401-462-2760
Practice Address - Fax:401-462-2757
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD058182080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F20634Medicare UPIN