Healthcare Provider Details

I. General information

NPI: 1578500955
Provider Name (Legal Business Name): SAMSON G VIMALANANDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 ROUTE 88 FL 3
BRICK NJ
08724-3018
US

IV. Provider business mailing address

120 SISTER PIERRE DR SUITE 403
TOWSON MA
21204
US

V. Phone/Fax

Practice location:
  • Phone: 732-295-6543
  • Fax:
Mailing address:
  • Phone: 410-827-6408
  • Fax: 443-279-0537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD20273
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA10657200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: