Healthcare Provider Details

I. General information

NPI: 1679913545
Provider Name (Legal Business Name): VIJI SUNDARAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR STE 902
JACKSONVILLE FL
32207-8336
US

IV. Provider business mailing address

836 PRUDENTIAL DR STE 902
JACKSONVILLE FL
32207-8336
US

V. Phone/Fax

Practice location:
  • Phone: 904-399-5620
  • Fax:
Mailing address:
  • Phone: 415-535-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberME162700
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number147967
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number006126
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: