Provider Demographics
NPI:1053691766
Name:SUNDARAM FAMILY MEDICAL CLINIC INC.
Entity type:Organization
Organization Name:SUNDARAM FAMILY MEDICAL CLINIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JAWAHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-589-0927
Mailing Address - Street 1:3001 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5827
Mailing Address - Country:US
Mailing Address - Phone:323-589-0927
Mailing Address - Fax:
Practice Address - Street 1:3001 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5827
Practice Address - Country:US
Practice Address - Phone:323-589-0927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67659207K00000X, 207Q00000X, 208D00000X
CAPA19004207Q00000X, 208D00000X
CA20A75662084P0804X, 208D00000X
CAPA190272208D00000X
CAPA19593208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty