Provider Demographics
NPI:1437224136
Name:LUSSIER, MARY LEONA (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEONA
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:250 WAMPANOAG TRL
Mailing Address - Street 2:STE 204
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2218
Mailing Address - Country:US
Mailing Address - Phone:401-438-2400
Mailing Address - Fax:401-438-2422
Practice Address - Street 1:250 WAMPANOAG TRL
Practice Address - Street 2:STE 204
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2218
Practice Address - Country:US
Practice Address - Phone:401-438-2400
Practice Address - Fax:401-438-2422
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD080522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050508380OtherHEALTHCARE VALUE MANAGEME
RI9002880Medicaid
103941700OtherDEPT OF LABOR WORKERS COM
RI406525OtherBLUE CHIP
MA111055OtherHARVARD PILGRIM HEALTH CA
RI139002880OtherMEDICARE PTAN
RI2635OtherNEIGHBORHOOD HEALTH PLAN
RI28808OtherBLUE CROSS BLUE SHIELD
8910896OtherCIGNA
0500318OtherUNITED HEALTH CARE
0500318OtherUNITED HEALTH CARE
RI139002880Medicare ID - Type Unspecified