Provider Demographics
NPI:1730138892
Name:SUNDARAM, SHANKAR M (MD)
Entity type:Individual
Prefix:DR
First Name:SHANKAR
Middle Name:M
Last Name:SUNDARAM
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 1:3085 WOODMAN DR STE 320
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1164
Mailing Address - Country:US
Mailing Address - Phone:937-795-1090
Mailing Address - Fax:937-795-1145
Practice Address - Street 1:3085 WOODMAN DR STE 320
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1171
Practice Address - Country:US
Practice Address - Phone:833-828-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.140498208600000X, 2086S0129X
MI4301503585208600000X, 2086S0129X
CODR.00696482086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H822401OtherMEDICARE PTAN