Provider Demographics
NPI:1770530321
Name:KONTRAKUL, SAM (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:KONTRAKUL
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 1:944 WASHINGTON ST
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1177
Mailing Address - Country:US
Mailing Address - Phone:508-238-8646
Mailing Address - Fax:508-230-9772
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-340-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36924208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2034999Medicaid
B87066Medicare UPIN
MAB18191Medicare ID - Type Unspecified