Healthcare Provider Details

I. General information

NPI: 1760555007
Provider Name (Legal Business Name): RAGHUNANDAN SUNDARAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 RAHWAY AVE
ELIZABETH NJ
07202-2212
US

IV. Provider business mailing address

7 RENEE CT
EDISON NJ
08820-3634
US

V. Phone/Fax

Practice location:
  • Phone: 908-355-7365
  • Fax: 908-355-2452
Mailing address:
  • Phone: 732-662-1403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07433200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: