Provider Demographics
NPI:1174515183
Name:PARAYATH, PADMAJA (MD)
Entity type:Individual
Prefix:
First Name:PADMAJA
Middle Name:
Last Name:PARAYATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5674
Mailing Address - Country:US
Mailing Address - Phone:508-565-0025
Mailing Address - Fax:508-894-0412
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5674
Practice Address - Country:US
Practice Address - Phone:508-565-0025
Practice Address - Fax:508-894-0412
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2024-01-12
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
MA51539207R00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3134148Medicaid
MAB97913Medicare UPIN
MA3134148Medicaid