Healthcare Provider Details

I. General information

NPI: 1285262253
Provider Name (Legal Business Name): SUNDER SHYAM GIDUMAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N ROXBURY DR STE 450
BEVERLY HILLS CA
90210-4231
US

IV. Provider business mailing address

450 N ROXBURY DR STE 450
BEVERLY HILLS CA
90210-4231
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA202526
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number724578891
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: