Provider Demographics
NPI:1518186840
Name:BAGAM, SAMATHA (MD)
Entity Type:Individual
Prefix:
First Name:SAMATHA
Middle Name:
Last Name:BAGAM
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 1:155 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4028
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:100 CRYSTAL RUN RD
Practice Address - Street 2:SUITE# 107
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4041
Practice Address - Country:US
Practice Address - Phone:845-703-6999
Practice Address - Fax:845-703-6297
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263259208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03111740Medicaid
NY03111740Medicaid