Provider Demographics
NPI:1902983976
Name:BARRETT, MARY THERESE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:THERESE
Last Name:BARRETT
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 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:19 FRIENDSHIP ST UNIT 220
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2264
Practice Address - Country:US
Practice Address - Phone:401-848-5556
Practice Address - Fax:401-845-4379
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD16855207V00000X
CO29546174400000X
IN01074809B207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1336399989Medicaid
CO01295468Medicaid
CO1568669943OtherGROUP
CO1902983976OtherPERSONAL
IN201268580Medicaid
COD25150Medicare UPIN
CO01295468Medicaid
IN201268580Medicaid