Provider Demographics
NPI:1285898890
Name:WARREN, OTIS UPSON (MD)
Entity type:Individual
Prefix:DR
First Name:OTIS
Middle Name:UPSON
Last Name:WARREN
Suffix:
Gender:M
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:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2008-07-12
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98804207PE0004X
RIMD12935207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI08/01/2009OtherUNITED HEALTHCARE
RI1962455022OtherUEMF GROUP NPI
RI07/30/2009OtherBCBS
MA09/22/2009OtherTUFTS HEALTH PLAN
RIOW76308Medicaid
RI001187301OtherMEDICARE
RI08/13/2009OtherNHPRI
MA11082647AMedicaid
RI939025129OtherMEDICARE GROUP NUMBER