Provider Demographics
NPI:1871517128
Name:MADOFF, SAMUEL DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DAVID
Last Name:MADOFF
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 1:15 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-4426
Mailing Address - Country:US
Mailing Address - Phone:424-298-0021
Mailing Address - Fax:
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-6687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2400292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001154001Medicare PIN