Healthcare Provider Details

I. General information

NPI: 1972130912
Provider Name (Legal Business Name): SAMUEL DAVID MALDONADO JR. MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET, BUL-1-130
BOSTON MA
02114
US

IV. Provider business mailing address

1215 LEE ST BOX 800744
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3906
  • Fax: 617-643-4237
Mailing address:
  • Phone: 434-924-1931
  • Fax: 434-243-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number1021380
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: