Healthcare Provider Details

I. General information

NPI: 1750330346
Provider Name (Legal Business Name): SUNDER MUDALIAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR # 111G
SAN DIEGO CA
92161-3254
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR # 111G
SAN DIEGO CA
92161-3254
US

V. Phone/Fax

Practice location:
  • Phone: 858-642-3152
  • Fax: 858-642-6242
Mailing address:
  • Phone: 858-642-3152
  • Fax: 858-642-6242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA52644
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA52644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: