Provider Demographics
NPI:1215913215
Name:SAN ANTONIO, PAMELA JO (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JO
Last Name:SAN ANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:161 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889
Mailing Address - Country:US
Mailing Address - Phone:401-737-4282
Mailing Address - Fax:401-738-6896
Practice Address - Street 1:161 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889
Practice Address - Country:US
Practice Address - Phone:401-737-4282
Practice Address - Fax:401-738-6896
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI6409208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9920040Medicaid
A3417AOtherHARVARD PILGRIM INS
1200217OtherUNITED HEALTH PLAN
RI200408OtherBCBS
406495OtherTUFTS HEALTH PLAN
RI6591OtherNEIGHBORHOOD HEALTH PLAN
4720780OtherCIGNA INSURANCE
RI201242OtherCHCP BLUE CHIP
RI6409OtherSTATE LICENSE
406495OtherTUFTS HEALTH PLAN