Provider Demographics
NPI:1306959358
Name:SUNDARAM, SHANKAR E (MD)
Entity type:Individual
Prefix:DR
First Name:SHANKAR
Middle Name:E
Last Name:SUNDARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2929 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2762
Mailing Address - Country:US
Mailing Address - Phone:858-939-6622
Mailing Address - Fax:858-874-5287
Practice Address - Street 1:2929 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2762
Practice Address - Country:US
Practice Address - Phone:858-939-6622
Practice Address - Fax:858-874-5287
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54007207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A540070Medicaid
CA00A540070Medicaid
CAH22740Medicare UPIN