Provider Demographics
NPI:1053530782
Name:THAVASEELAN, SIMONE
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:THAVASEELAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 COLLYER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1869
Mailing Address - Country:US
Mailing Address - Phone:401-272-7799
Mailing Address - Fax:401-272-9299
Practice Address - Street 1:2 DUDLEY ST STE 185
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3247
Practice Address - Country:US
Practice Address - Phone:401-444-5795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD13391208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI349005986OtherMEDICARE GROUP PTAN
1659463230OtherGROUP NPI
1659463230OtherGROUP NPI