Healthcare Provider Details

I. General information

NPI: 1013960285
Provider Name (Legal Business Name): KALYANA SUNDARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 EAST DONALD STREET
WATERLOO IA
50703-1223
US

IV. Provider business mailing address

PO BOX 2758
WATERLOO IA
50704-2758
US

V. Phone/Fax

Practice location:
  • Phone: 319-236-1911
  • Fax: 319-287-5832
Mailing address:
  • Phone: 319-235-5390
  • Fax: 319-233-1630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number29047
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: