Provider Demographics
NPI:1568415461
Name:SADHUJAN, PRABHASADANAM G
Entity Type:Individual
Prefix:DR
First Name:PRABHASADANAM
Middle Name:G
Last Name:SADHUJAN
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 1:200 LINCOLN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2528
Mailing Address - Country:US
Mailing Address - Phone:508-755-1222
Mailing Address - Fax:508-754-7020
Practice Address - Street 1:200 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2528
Practice Address - Country:US
Practice Address - Phone:508-755-1222
Practice Address - Fax:508-754-7020
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220110207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G81569Medicare UPIN
MAA36561Medicare ID - Type Unspecified