Provider Demographics
NPI:1326065384
Name:ANDONIAN, SAMUEL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:ANDONIAN
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 1:16 CLARKE ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4948
Mailing Address - Country:US
Mailing Address - Phone:781-862-3218
Mailing Address - Fax:781-862-0805
Practice Address - Street 1:16 CLARKE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4948
Practice Address - Country:US
Practice Address - Phone:781-862-3218
Practice Address - Fax:781-862-0805
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37648208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD28132OtherBSBS 20465 MASS
MA037648OtherTUFTS
MA2025698Medicaid
MAD28132OtherBSBS 20465 MASS