Provider Demographics
NPI:1437156395
Name:PODDAR, PRODYUT K
Entity Type:Individual
Prefix:
First Name:PRODYUT
Middle Name:K
Last Name:PODDAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MAIN STREET
Mailing Address - Street 2:SUITE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-438-6368
Practice Address - Street 1:800 W. CUMMINGS PARK
Practice Address - Street 2:SUITE 4700
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6372
Practice Address - Country:US
Practice Address - Phone:781-932-6487
Practice Address - Fax:781-932-6486
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50729208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2076551Medicaid
MA2076551Medicaid
MAJ01180Medicare ID - Type Unspecified