Provider Demographics
NPI:1578500955
Name:VIMALANANDA, SAMSON G (MD)
Entity Type:Individual
Prefix:
First Name:SAMSON
Middle Name:G
Last Name:VIMALANANDA
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 1:120 SISTER PIERRE DR
Mailing Address - Street 2:SUITE 403
Mailing Address - City:TOWSON
Mailing Address - State:MA
Mailing Address - Zip Code:21204
Mailing Address - Country:US
Mailing Address - Phone:410-827-6408
Mailing Address - Fax:443-279-0537
Practice Address - Street 1:1610 ROUTE 88 FL 3
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3018
Practice Address - Country:US
Practice Address - Phone:732-295-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD202732084P0800X
NJ25MA106572002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
461905000OtherMAGE
PVPB76641OtherAPS
0019OtherBSDC
595882OtherMAMS
096890OtherMHN
1023561OtherCIGN
253557OtherCOMP
150N131GOtherMBMD
221073OtherKAIS
42225312OtherBSMD