Healthcare Provider Details

I. General information

NPI: 1306821921
Provider Name (Legal Business Name): KRISHNAMURTHI SUNDARAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 6TH AVE
BROOKLYN NY
11215-8021
US

IV. Provider business mailing address

450 CLARKSON AVE BOX 126
BROOKLYN NY
11203-2056
US

V. Phone/Fax

Practice location:
  • Phone: 718-499-0940
  • Fax: 718-499-2912
Mailing address:
  • Phone: 718-270-1638
  • Fax: 718-270-3924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number137456-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: