Provider Demographics
NPI:1669450102
Name:PUDIMAT, PAUL ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALLEN
Last Name:PUDIMAT
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 1:3998 FAIR RIDGE DRIVE, SUITE 300
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:61 EMERALD GLEN RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-4123
Practice Address - Country:US
Practice Address - Phone:860-887-9053
Practice Address - Fax:860-887-9073
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037393207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001573935Medicaid
G84032Medicare UPIN
CT050001077Medicare PIN