MEDICARE: DR. PAMELA S UDOMPRASERT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	045967	CT
2	208000000X	Pediatrics Physician	042-0012099	VT
3	208000000X	Pediatrics Physician	16930	NH

General Provider Information

NPI Number	:	1346437340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAMELA S UDOMPRASERT MD

Provider Business Mailing Address
First Line	:	44 S MAIN ST
Second Line	:
City	:	RANDOLPH
State	:	VT
Zip	:	05060-1381
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	245 ROCHESTER HILL RD STE 2
Second Line	:
City	:	ROCHESTER
State	:	NH
Zip	:	03867-1709
Country	:	US
Telephone Number	:	603-332-0238
Fax Number	:	603-332-7098

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	01/27/2022

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