Provider Demographics
NPI:1134186067
Name:ETTENSOHN, DAVID B (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:ETTENSOHN
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 1:73 BEECHWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-724-4040
Mailing Address - Fax:401-722-9575
Practice Address - Street 1:73 BEECHWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-724-4040
Practice Address - Fax:401-722-9575
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI6164207RC0200X, 207RP1001X
RI06164207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI6164OtherRI MEDICAL LICENSE #
RI7000422Medicaid
RI007006915Medicare ID - Type UnspecifiedMEDICARE NUMBER
RI7000422Medicaid