Provider Demographics
NPI:1679511315
Name:SUNDERRAJAN, ETTAYAPURUM V (MD)
Entity type:Individual
Prefix:DR
First Name:ETTAYAPURUM
Middle Name:V
Last Name:SUNDERRAJAN
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 1:11180 WARNER AVE
Mailing Address - Street 2:SUITE 253
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7501
Mailing Address - Country:US
Mailing Address - Phone:714-979-2825
Mailing Address - Fax:714-979-2862
Practice Address - Street 1:11180 WARNER AVE
Practice Address - Street 2:SUITE 253
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7501
Practice Address - Country:US
Practice Address - Phone:714-979-2825
Practice Address - Fax:714-979-2862
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42385207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330387285OtherBLUE CROSS OF CALIFORNIA
CA330387825OtherAETNA
CAZZZ33736ZOtherBLUE SHIELD OF CALIFORNIA
CA330387285OtherUNITED HEALTHCARE/PACIFICARE
CAGR0053330OtherCAL-OPTIMA
CAW11174Medicare ID - Type UnspecifiedMEDICARE GROUP NO.
CAA85792Medicare UPIN
CA110022448Medicare PIN