Provider Demographics
NPI:1063595783
Name:SUNDMAN, MICHAEL RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:SUNDMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 GILLETTE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06057-2809
Mailing Address - Country:US
Mailing Address - Phone:860-496-1922
Mailing Address - Fax:
Practice Address - Street 1:1400 FARMINGTON AVE
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4701
Practice Address - Country:US
Practice Address - Phone:860-585-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020398OtherCONNECTICARE
CT090002398CT02OtherANTHEM BC/BS