Provider Demographics
NPI:1609654136
Name:SAMUEL GNANAM, JOEL KEVIN RAJ (MBBS, MD)
Entity Type:Individual
Prefix:DR
First Name:JOEL KEVIN RAJ
Middle Name:
Last Name:SAMUEL GNANAM
Suffix:
Gender:M
Credentials:MBBS, MD
Other - Prefix:
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Mailing Address - Street 1:62 BOYLSTON ST APT 622
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-4790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST RM 197
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-5246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA30153712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology