Healthcare Provider Details

I. General information

NPI: 1669820858
Provider Name (Legal Business Name): MOHAN SUNDARESON M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 SOUTH GRANT ST
SAN MATEO CA
94402
US

IV. Provider business mailing address

1638, SOUTH GRANT STREET
SAN MATEO CA
94402
US

V. Phone/Fax

Practice location:
  • Phone: 650-571-6283
  • Fax:
Mailing address:
  • Phone: 650-571-6283
  • Fax: 650-571-6283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40596
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: