1457342420 NPI number — DR. SAMIR PRAVINCHANDRA PATEL M.D.

Table of content: DR. SAMIR PRAVINCHANDRA PATEL M.D. (NPI 1457342420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457342420 NPI number — DR. SAMIR PRAVINCHANDRA PATEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATEL
Provider First Name:
SAMIR
Provider Middle Name:
PRAVINCHANDRA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457342420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 FELLSMERE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01880-3681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-246-2747
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEWKSBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01876-1950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-306-6165
Provider Business Practice Location Address Fax Number:
781-306-6146
Provider Enumeration Date:
10/31/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0805X , with the licence number:  76085 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 83588 . This is a "UNITED BEH HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 076805 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3112608 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".