Provider Demographics
NPI:1376526350
Name:PATHAK, ANU RADHA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANU
Middle Name:RADHA
Last Name:PATHAK
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 1:85 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4005
Mailing Address - Country:US
Mailing Address - Phone:508-765-2700
Mailing Address - Fax:508-764-2563
Practice Address - Street 1:85 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4005
Practice Address - Country:US
Practice Address - Phone:508-765-2700
Practice Address - Fax:508-764-2563
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3195074Medicaid
MA3195074Medicaid
G94945Medicare UPIN