Healthcare Provider Details

I. General information

NPI: 1932138583
Provider Name (Legal Business Name): SHOBANA SUNDARAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43184 DEQUINDRE RD STE 208
STERLING HEIGHTS MI
48314
US

IV. Provider business mailing address

43184 DEQUINDRE RD STE 208
STERLING HEIGHTS MI
48314
US

V. Phone/Fax

Practice location:
  • Phone: 586-731-1500
  • Fax: 586-731-1363
Mailing address:
  • Phone: 586-731-1500
  • Fax: 586-731-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301077847
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: