1629063318 NPI number — MAMATHA SUNDARESH MD

Table of content: MAMATHA SUNDARESH MD (NPI 1629063318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629063318 NPI number — MAMATHA SUNDARESH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNDARESH
Provider First Name:
MAMATHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629063318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
977 48TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11219-2919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-283-8015
Provider Business Mailing Address Fax Number:
718-635-7235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4802 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11219-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-283-7500
Provider Business Practice Location Address Fax Number:
718-635-7235
Provider Enumeration Date:
09/19/2005

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: 208000000X , with the licence number:  190550 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01480813 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-3563769 . This is a "HORIZON HEALTHCARE NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4604933 . This is a "AETNA PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2163738 . This is a "OXFORD HEALTH PLANS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 190550-F15 . This is a "HEALTH FIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2698609 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2563948 . This is a "AETNA USHC HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 300950401 . This is a "HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: BK00828-03 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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