MEDICARE: SUNDARAM FAMILY MEDICAL CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A67659	CA

General Provider Information

NPI Number	:	1518110287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNDARAM FAMILY MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	987 W VERNON AVE AND
Second Line	:	10410 LOWER AZUSA RD #101 EL MONTE CA 91731
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-3038
Country	:	US
Telephone Number	:	323-234-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	987 W. VERNON AVE AND
Second Line	:	10410 LOWER AZUSA RD #104 EL MONTE CA. 91731
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-3038
Country	:	US
Telephone Number	:	323-234-6300
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAWAHAR SUNDRARAM
Credential	:	MD
Telephone Number	:	323-234-6300

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	09/28/2016

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