Provider Demographics
NPI:1750475992
Name:GAUTHIER, EDWARD J (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:GAUTHIER
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:PO BOX 8879
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-0879
Mailing Address - Country:US
Mailing Address - Phone:401-572-3120
Mailing Address - Fax:401-572-3351
Practice Address - Street 1:1332 SMITH ST
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-3303
Practice Address - Country:US
Practice Address - Phone:401-273-5277
Practice Address - Fax:401-751-2980
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI3421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
64950RIHOtherPILGRIM
RI7018OtherBLUE CROSS/ BLUE SHIELD
RI3421OtherLICENSE
RI000856OtherBC/BS BLUECHIP
RI9000701Medicaid
0400505OtherUNITED HEALTH
64950RIHOtherPILGRIM
RI119000701Medicare PIN