Provider Demographics
NPI:1053488098
Name:SOODAN, RAVINDER S (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDER
Middle Name:S
Last Name:SOODAN
Suffix:
Gender:M
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:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:S WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190
Mailing Address - Country:US
Mailing Address - Phone:781-331-2010
Mailing Address - Fax:781-340-9915
Practice Address - Street 1:72 SHARP ST
Practice Address - Street 2:SUITE A10
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043
Practice Address - Country:US
Practice Address - Phone:781-331-2010
Practice Address - Fax:781-340-9915
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3038131Medicaid
64627OtherHARVARD PILGRIM
J07570OtherBCBS
059327OtherTUFTS
B75034Medicare UPIN
MAJ07570Medicare ID - Type Unspecified