Provider Demographics
NPI:1083797492
Name:TANDON, DEEPAK SHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:SHAM
Last Name:TANDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:125 PARKER HILL
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120
Mailing Address - Country:US
Mailing Address - Phone:617-731-0016
Mailing Address - Fax:617-739-6866
Practice Address - Street 1:125 PARKER HILL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120
Practice Address - Country:US
Practice Address - Phone:617-731-0016
Practice Address - Fax:617-739-6866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA465652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA92688OtherAETNA
MA706450OtherTUFTS
MA11151OtherHPHC
MAVC6000170977OtherCOMMONWEALTH OF MA
MAM14268OtherBCBS
MAM14268OtherBCBS
MA92688OtherAETNA