Provider Demographics
NPI:1518247329
Name:SAMAROO, MAHENDRA JADUNAUTH
Entity Type:Individual
Prefix:
First Name:MAHENDRA
Middle Name:JADUNAUTH
Last Name:SAMAROO
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 1:8544 150TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2826
Mailing Address - Country:US
Mailing Address - Phone:718-657-5785
Mailing Address - Fax:
Practice Address - Street 1:8544 150TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-2826
Practice Address - Country:US
Practice Address - Phone:718-657-5785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014926363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPV2321UMedicaid