Provider Demographics
NPI:1154360469
Name:IANNOTTI, HARRY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:MICHAEL
Last Name:IANNOTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1165 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-521-4333
Mailing Address - Fax:401-521-4377
Practice Address - Street 1:1165 N MAIN ST
Practice Address - Street 2:STE. 200
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5740
Practice Address - Country:US
Practice Address - Phone:401-521-4333
Practice Address - Fax:401-521-4377
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD04154208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020353Medicaid
RIC90557Medicare UPIN
RI9020353Medicaid