Basic Information
| Provider Information | |||||||||
| NPI: | 1437156395 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PODDAR | ||||||||
| FirstName: | PRODYUT | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN STREET | ||||||||
| Address2: | SUITE 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386368 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W. CUMMINGS PARK | ||||||||
| Address2: | SUITE 4700 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018016372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819326487 | ||||||||
| FaxNumber: | 7819326486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 50729 | MA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 2076551 | 05 | MA | MEDICAID |