Provider Demographics
NPI:1962459008
Name:SAMUDRALA, BABURAO N (MD)
Entity type:Individual
Prefix:
First Name:BABURAO
Middle Name:N
Last Name:SAMUDRALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0340
Mailing Address - Country:US
Mailing Address - Phone:315-732-9368
Mailing Address - Fax:315-732-9403
Practice Address - Street 1:460 ANDES RD
Practice Address - Street 2:PHYSICIANS OFFICE BUILDING
Practice Address - City:DELHI
Practice Address - State:NY
Practice Address - Zip Code:13753-7407
Practice Address - Country:US
Practice Address - Phone:607-746-6266
Practice Address - Fax:607-746-6266
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138827-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00492026Medicaid
NY00492026Medicaid
DCAS8909422OtherDEA
NY00492026Medicaid