Healthcare Provider Details

I. General information

NPI: 1164501185
Provider Name (Legal Business Name): SUDHA KUNCHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E WOODSIDE AVE
PATCHOGUE NY
11772-1421
US

IV. Provider business mailing address

2428 MERRICK RD
BELLMORE NY
11710-5704
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-6565
  • Fax: 631-758-6568
Mailing address:
  • Phone: 516-379-2689
  • Fax: 516-867-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number159205
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: