Provider Demographics
NPI:1699713008
Name:SUNDAR, SUBRAMANIAM BALA (MD)
Entity type:Individual
Prefix:
First Name:SUBRAMANIAM
Middle Name:BALA
Last Name:SUNDAR
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 1:2423 BRANDONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406
Mailing Address - Country:US
Mailing Address - Phone:205-345-3685
Mailing Address - Fax:
Practice Address - Street 1:1774 MCFARLAND BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406
Practice Address - Country:US
Practice Address - Phone:205-759-2920
Practice Address - Fax:205-759-1344
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11821207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051512201Medicaid
AL51512201OtherBCBS
AL51512201OtherBCBS
051512201Medicare ID - Type Unspecified