Provider Demographics
NPI:1780705707
Name:BEVIVINO, JACK R (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:BEVIVINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DUDLEY STREET
Mailing Address - Street 2:SUITE #201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2431
Mailing Address - Country:US
Mailing Address - Phone:401-521-9290
Mailing Address - Fax:401-521-9297
Practice Address - Street 1:120 DUDLEY STREET
Practice Address - Street 2:SUITE #201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2431
Practice Address - Country:US
Practice Address - Phone:401-521-9290
Practice Address - Fax:401-521-9297
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRIMD05259208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1300124OtherUNITED HEALTH CARE
RI9002112Medicaid
RI21126OtherBCBS
C90377Medicare UPIN