Provider Demographics
NPI:1982057154
Name:SUNDARAMOORTHY, MATHURAN
Entity type:Individual
Prefix:
First Name:MATHURAN
Middle Name:
Last Name:SUNDARAMOORTHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2203
Mailing Address - Country:US
Mailing Address - Phone:866-682-4842
Mailing Address - Fax:409-772-5462
Practice Address - Street 1:2101 TENAYA DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-3930
Practice Address - Country:US
Practice Address - Phone:866-682-4842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine