Healthcare Provider Details

I. General information

NPI: 1780798686
Provider Name (Legal Business Name): YELENA SAMOFALOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST STE 102
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

PO BOX 40
SOUTHBRIDGE MA
01550-0040
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-7860
  • Fax: 508-765-7861
Mailing address:
  • Phone: 508-909-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number223642
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: