Healthcare Provider Details

I. General information

NPI: 1790004752
Provider Name (Legal Business Name): SOUMEN SAMADDAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 ROUTE 31 N
PENNINGTON NJ
08534-3605
US

IV. Provider business mailing address

84 ROUTE 31 N SUITE 103
PENNINGTON NJ
08534-3605
US

V. Phone/Fax

Practice location:
  • Phone: 609-730-1771
  • Fax: 609-730-1274
Mailing address:
  • Phone: 609-730-1771
  • Fax: 609-730-1274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA08767300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: