Provider Demographics
NPI:1194804831
Name:PONTARELLI, BRIAN F (DPM)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:F
Last Name:PONTARELLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 WAMPANOAG TRAIL
Mailing Address - Street 2:SUITE 205 RHODE ISLAND FOOT CARE INC
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02915
Mailing Address - Country:US
Mailing Address - Phone:401-431-0283
Mailing Address - Fax:401-438-5956
Practice Address - Street 1:486 SILVER SPRING ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-751-2660
Practice Address - Fax:401-751-9990
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00294213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7007118Medicaid
U74660Medicare UPIN
RI7007118Medicaid