Provider Demographics
NPI:1962066878
Name:KETHEESWARAN, PAVINARMATHA (MD)
Entity type:Individual
Prefix:
First Name:PAVINARMATHA
Middle Name:
Last Name:KETHEESWARAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-444-0400
Mailing Address - Fax:401-444-0468
Practice Address - Street 1:40 CANDACE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-3747
Practice Address - Country:US
Practice Address - Phone:401-444-0550
Practice Address - Fax:401-444-0425
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP04636207Q00000X
390200000X
RIMD18615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program