Healthcare Provider Details

I. General information

NPI: 1851218259
Provider Name (Legal Business Name): GIDUMAL MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11820 MAYFIELD AVE APT 215
LOS ANGELES CA
90049-5771
US

IV. Provider business mailing address

11820 MAYFIELD AVE APT 215
LOS ANGELES CA
90049-5771
US

V. Phone/Fax

Practice location:
  • Phone: 646-801-2480
  • Fax: 646-801-2480
Mailing address:
  • Phone: 646-801-2480
  • Fax: 646-801-2480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SUNDER GIDUMAL
Title or Position: OWNER
Credential: MD
Phone: 917-566-6720