Provider Demographics
NPI:1457448086
Name:MAHAPATRA, SOURYA RANJAN (MD)
Entity Type:Individual
Prefix:
First Name:SOURYA
Middle Name:RANJAN
Last Name:MAHAPATRA
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 1:280 MAIN ST STE 210A
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-2920
Mailing Address - Country:US
Mailing Address - Phone:603-577-3080
Mailing Address - Fax:
Practice Address - Street 1:NASHUA CENTER FOR HEALTHY AGING
Practice Address - Street 2:280 MAIN ST., #210A
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060
Practice Address - Country:US
Practice Address - Phone:603-577-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12394207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204441Medicaid
NHRE 7782Medicare ID - Type Unspecified
I 11772Medicare UPIN