Healthcare Provider Details

I. General information

NPI: 1902324528
Provider Name (Legal Business Name): SUDARSAN KOLLIMUTTATHUILLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2017
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 SAND CANYON AVE STE 207
IRVINE CA
92618-3712
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 949-333-7580
  • Fax: 949-333-7599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA169385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: