Provider Demographics
NPI:1689657306
Name:SAMPATH, PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:SAMPATH
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 1:118 DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2403
Mailing Address - Country:US
Mailing Address - Phone:401-273-4155
Mailing Address - Fax:401-273-4115
Practice Address - Street 1:120 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2436
Practice Address - Country:US
Practice Address - Phone:401-273-4155
Practice Address - Fax:401-273-4115
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205361207T00000X
RIMD10126207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G73446Medicare UPIN