Provider Demographics
NPI:1063568194
Name:TAVAKOLI, HASAN D (DA)
Entity type:Individual
Prefix:DR
First Name:HASAN
Middle Name:D
Last Name:TAVAKOLI
Suffix:
Gender:M
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 EDDIE DOWLING HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-7327
Mailing Address - Country:US
Mailing Address - Phone:401-766-0800
Mailing Address - Fax:401-765-5904
Practice Address - Street 1:116 EDDIE DOWLING HWY
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-7327
Practice Address - Country:US
Practice Address - Phone:401-766-0800
Practice Address - Fax:401-765-5904
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00050171100000X
MA388171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI406785OtherBLUE CHIP
RI22033-0OtherBLUE CROSS OF RHODE ISLAN
RI611262OtherUNITED HEALTH
MAQ00403OtherBLUE CROSS OF MA
RI0003OtherCIGNA