Provider Demographics
NPI:1720068307
Name:COMEAU, DONNELLA SIMONE (MD PHD)
Entity Type:Individual
Prefix:
First Name:DONNELLA
Middle Name:SIMONE
Last Name:COMEAU
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:DONELLA
Other - Middle Name:SIMONE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD PHD
Mailing Address - Street 1:190 ELMGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4233
Mailing Address - Country:US
Mailing Address - Phone:781-962-8621
Mailing Address - Fax:
Practice Address - Street 1:525 BROAD ST
Practice Address - Street 2:ADVANCED RADIOLOGY
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-6919
Practice Address - Country:US
Practice Address - Phone:401-725-6736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2238202085R0202X
RIMD120032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ29652OtherBLOE CROSS BLUE SHIELD
MA2112710Medicaid
MA294444OtherTUFTS HEALTH CARE
MA294444OtherTUFTS HEALTH CARE
MAG0A39469Medicare ID - Type Unspecified