1821083031 NPI number — DR. VENKATACHALAM SHANMUGASUNDARAM MD

Table of content: DR. VENKATACHALAM SHANMUGASUNDARAM MD (NPI 1821083031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821083031 NPI number — DR. VENKATACHALAM SHANMUGASUNDARAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANMUGASUNDARAM
Provider First Name:
VENKATACHALAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUNDARAM
Provider Other First Name:
V.S.
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821083031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10131 W FOREST HILL BLVD STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLINGTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33414-6109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-798-6767
Provider Business Mailing Address Fax Number:
561-795-2706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10131 W FOREST HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33414-6156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-798-6767
Provider Business Practice Location Address Fax Number:
561-795-2706
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  ME0045705 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00446 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3370WELL . This is a "NIEGHBORHOOD PATNERS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 592607590 . This is a "CHAMPUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0067235 . This is a "GHI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1002118 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3370WELL . This is a "NEIGHBORHOOD PARTNERS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00446 . This is a "STAYWELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 592607590 . This is a "VISTA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 205868 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 61449 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 040885901 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0854223 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 592607590A . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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