Healthcare Provider Details

I. General information

NPI: 1457448086
Provider Name (Legal Business Name): SOURYA RANJAN MAHAPATRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NASHUA CENTER FOR HEALTHY AGING 280 MAIN ST., #210A
NASHUA NH
03060
US

IV. Provider business mailing address

280 MAIN ST STE 210A
NASHUA NH
03060-2920
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-3080
  • Fax:
Mailing address:
  • Phone: 603-577-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number12394
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: