Basic Information
| Provider Information | |||||||||
| NPI: | 1629106679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DHANABALAN | ||||||||
| FirstName: | UMA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH, FAAFP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | ROOM 339 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625612 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 OAK ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023011168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088974711 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | 157551 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2300X | 157551 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | Z006251 | 05 | MA | MEDICAID | 1319219 | 01 | MA | AETNA | OTHER | AA65606 | 01 | MA | HARVARD PILGRIM | OTHER | J26406 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |