Healthcare Provider Details

I. General information

NPI: 1457342420
Provider Name (Legal Business Name): SAMIR PRAVINCHANDRA PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 EAST ST
TEWKSBURY MA
01876-1950
US

IV. Provider business mailing address

14 FELLSMERE AVE
WAKEFIELD MA
01880-3681
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-6165
  • Fax: 781-306-6146
Mailing address:
  • Phone: 781-246-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number76085
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: