Basic Information
| Provider Information | |||||||||
| NPI: | 1487675377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEARON | ||||||||
| FirstName: | DEIRDRE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9484 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029409484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542508 | ||||||||
| FaxNumber: | 4018542519 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | CLAVERICK 2 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542504 | ||||||||
| FaxNumber: | 4018542519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD10068 | RI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | MD10068 | RI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7007378 | 05 | RI | MEDICAID | 939025129 | 01 | RI | RI MEDICARE GROUP NUMBER | OTHER | 1487675377 | 01 | RI | NPI | OTHER | 370015303 | 01 | RI | RAILROAD MEDICARE | OTHER | 12/14/2006 | 01 | RI | NHPRI | OTHER | 12/29/2008 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 3204898 | 05 | MA | MEDICAID |